J A N U A R Y 3 0 , 2 0 0 4

OF THE

NASA AGENCY-WIDE APPLICABILITY

OF THE

COLUMBIA ACCIDENT INVESTIGATION BOARD 

REPORT

A RENEWED COMMITMENT TO EXCELLENCE
i i
1

February 1, 2003 was a turning point in the history of NASA. February February February February February February February February February February February February 1, 2003 was a turning turning turning turning turning turning turning turning turning turning turning turning point in the history history history history history history history history history history history history of NASA. 

There had been accidents before the loss of Shuttle There had been accidents accidents accidents accidents accidents accidents accidents accidents accidents before the loss of Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Columbia

and its crew, and there had been Agency reviews, both internal and its crew, and there had been Agency reviews, reviews, reviews, reviews, reviews, reviews, reviews, reviews, reviews, reviews, reviews, reviews, both internal internal internal internal internal internal internal internal internal internal internal internal 

and external. Although these prior accidents and subsequent in- and external. external. external. external. external. external. external. external. external. external. external. Although Although Although Although Although Although Although Although Although Although Although these prior accidents accidents accidents accidents accidents accidents accidents accidents accidents accidents accidents and subsequent subsequent subsequent subsequent subsequent subsequent subsequent subsequent subsequent subsequent subsequent investigations provided NASA opportunities to learn and evolve, vestigations vestigations vestigations vestigations vestigations vestigations vestigations vestigations vestigations vestigations vestigations vestigations provided provided provided provided provided provided provided provided provided provided provided provided NASA opportunities opportunities opportunities opportunities opportunities opportunities opportunities opportunities opportunities opportunities opportunities opportunities to learn and evolve, evolve, evolve, evolve, evolve, evolve, evolve, evolve, evolve, evolve, evolve, evolve, 

the Columbia accident made it painfully clear that NASAʼs safety accident accident accident accident accident accident accident accident accident made it painfully painfully painfully painfully painfully painfully painfully painfully painfully clear that NASAʼs safety 

and reliability performance was still falling short. What was lost and reliability reliability reliability reliability reliability reliability reliability reliability reliability reliability reliability performance performance performance performance performance performance performance performance performance performance performance was still falling falling falling falling falling falling falling falling falling falling falling short. What was lost 

that day were not only seven lives and an historic spacecraft, but that day were not only seven lives and an historic historic historic historic historic historic historic historic historic historic historic historic spacecraft, spacecraft, spacecraft, spacecraft, spacecraft, spacecraft, spacecraft, spacecraft, spacecraft, spacecraft, spacecraft, spacecraft, but 

also the confi dence that NASA knew how to identify problems also the confidence that NASA knew how to identify identify identify identify identify identify identify identify identify identify identify problems problems problems problems problems problems problems problems problems problems problems 

and resolve them properly. and resolve them properly.

The Columbia Accident Investigation Board (CAIB) was estab- The Columbia Accident Investigation Board (CAIB) was established within hours of the Shuttleʼs loss, and the Board proceeded lished within hours of the Shuttleʼs loss, and the Board proceeded

to work independently and thoroughly to fi gure out what went to work independently and thoroughly to figure out what went

wrong. Accident investigators traditionally include a determina- wrong. Accident investigators traditionally include a determination of “probable cause” in their reports, but the CAIB Report has tion of “probable cause” in their reports, but the CAIB Report has

two causal statements, one “physical,” the other “organizational.” two causal statements, one “physical,” the other “organizational.”

The physical causes are the sequence of events on Shuttle Mission The physical causes are the sequence of events on Shuttle Mission

STS-107 that destroyed the Orbiter; the organizational causes are STS-107 that destroyed the Orbiter; the organizational causes are

the failures within NASA that allowed those events to occur. the failures within NASA that allowed those events to occur.

The CAIB released its Report in August 2003, followed by fi ve The CAIB released released released released released released released released released released released its Report in August 2003, followed followed followed followed followed followed followed followed followed followed followed by five 

volumes of appendix material in October, and with that the volumes volumes volumes volumes volumes volumes volumes volumes volumes volumes volumes of appendix appendix appendix appendix appendix appendix appendix appendix appendix appendix appendix material material material material material material material material material material material in October October October October October October October October October October October, and with that the 

Boardʼs work was concluded. But the job for NASA was just Boardʼs work was concluded. concluded. concluded. concluded. concluded. concluded. concluded. concluded. concluded. concluded. concluded. But the job for NASA was just 

beginning. In the months following the loss of beginning. beginning. beginning. beginning. beginning. beginning. beginning. beginning. In the months following following following following following following following following the loss of Columbia and her and her 

crew, the Agency had been making both technical and procedural crew, the Agency had been making both technical technical technical technical technical technical technical technical technical technical technical technical and procedural procedural procedural procedural procedural procedural procedural procedural procedural procedural procedural procedural 

changes, based on its own examination of the accident and on changes, changes, changes, changes, changes, changes, changes, changes, changes, changes, changes, based on its own examination examination examination examination examination examination examination examination examination examination examination of the accident accident accident accident accident accident accident accident accident accident accident and on 

interim recommendations from the CAIB. Once the investigation interim interim interim interim interim interim interim interim interim interim interim interim recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations from the CAIB. Once the investigation investigation investigation investigation investigation investigation investigation investigation investigation investigation investigation investigation 

Report was made public, those efforts accelerated. Report was made public, those efforts accelerated.

The NASA Administrator Sean OʼKeefe chartered an executive The NASA Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Sean OʼKeefe OʼKeefe OʼKeefe OʼKeefe OʼKeefe OʼKeefe OʼKeefe OʼKeefe OʼKeefe OʼKeefe OʼKeefe chartered chartered chartered chartered chartered chartered chartered chartered chartered chartered chartered an executive executive executive executive executive executive executive executive executive executive executive 

team, which came to be known as the Diaz Team, and gave it team, which came to be known as the Diaz Team, and gave it 

the assignment of identifying those CAIB Report elements with the assignment assignment assignment assignment assignment assignment assignment assignment assignment assignment assignment assignment of identifying identifying identifying identifying identifying identifying identifying identifying identifying identifying identifying identifying those CAIB Report elements elements elements elements elements elements elements elements elements elements elements elements with 

Agency-wide applicability and developing measures to address Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability and developing developing developing developing developing developing developing developing developing developing developing measures measures measures measures measures measures measures measures measures measures measures to address address address address address address address address address address address 

each one. What follows is the Report of that team. It should be each one. What follows follows follows follows follows follows follows follows follows follows follows follows is the Report of that team. It should be 

noted that while the Team focused on the organizational causes noted that while the Team focused focused focused focused focused focused focused focused focused focused focused on the organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational causes 

described in the CAIB Report which were related to NASAʼs described described described described described described described described described described described described in the CAIB Report which were related related related related related related related related related related related related to NASAʼs 

culture, the Team did not do a broad, in-depth assessment of the culture, culture, culture, culture, culture, culture, culture, culture, culture, culture, culture, the Team did not do a broad, in-depth in-depth in-depth in-depth in-depth in-depth in-depth in-depth in-depth in-depth in-depth assessment assessment assessment assessment assessment assessment assessment assessment assessment assessment assessment of the 

cultural changes needed to address the organizational causes. cultural cultural cultural cultural cultural cultural cultural cultural cultural cultural cultural cultural changes changes changes changes changes changes changes changes changes changes changes changes needed to address address address address address address address address address address address address the organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational causes. causes. causes. causes. causes. causes. causes. causes. causes. causes. causes. causes. 

The Team focused specifi cally on the CAIB Report and those The Team focused focused focused focused focused focused focused focused focused focused focused specifi specically on the CAIB Report and those 

Recommendations, Observations, and Findings (R-O-Fs) that Recommendations, Recommendations, Recommendations, Recommendations, Recommendations, Recommendations, Recommendations, Recommendations, Recommendations, Recommendations, Recommendations, Observations, Observations, Observations, Observations, Observations, Observations, Observations, Observations, Observations, Observations, Observations, and Findings Findings Findings Findings Findings Findings Findings Findings Findings Findings Findings (R-O-Fs) (R-O-Fs) (R-O-Fs) (R-O-Fs) (R-O-Fs) (R-O-Fs) (R-O-Fs) (R-O-Fs) (R-O-Fs) (R-O-Fs) (R-O-Fs) that 

had broad Agency-wide application beyond the Human Space had broad Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide application application application application application application application application application application application application beyond the Human Space 

Flight Program. Admittedly, some of the actions recommended Flight Program. Program. Program. Program. Program. Program. Program. Program. Program. Program. Program. Admittedly Admittedly Admittedly Admittedly Admittedly Admittedly Admittedly Admittedly Admittedly Admittedly Admittedly, some of the actions actions actions actions actions actions actions actions actions actions actions recommended recommended recommended recommended recommended recommended recommended recommended recommended recommended recommended 

by the Team are actions one would ex- by the Team are actions actions actions actions actions actions actions actions one would expect to see an organization take if it were pect to see an organization ganization ganization ganization ganization ganization ganization take if it were 

trying to change its culture, but the goals trying to change its culture, culture, culture, culture, culture, culture, culture, culture, but the goals 

offered by the Team are intended as only offered by the Team are intended intended intended intended intended intended intended as only 

a fi rst step in the process. a first step in the process. 

Had the fate of STS-107 been the result of Had the fate of STS-107 STS-107 STS-107 STS-107 STS-107 STS-107 STS-107 been the result of 

a small number of well-defi ned problems a small number of well-defi well-defi well-defi well-defi well-defi well-defi well-defi well-defined problems problems problems problems problems problems problems problems 

in a single program, fi nding solutions in a single program, program, program, program, program, program, program, finding solutions solutions solutions solutions solutions solutions solutions 

would be a relatively straightforward would be a relatively straightforward 

matter. But the CAIB determined that matter. But the CAIB determined determined determined determined determined determined determined that 

such is not the case. It was their conclu- such is not the case. It was their conclu- conclu- conclu- conclu- conclu- conclu- conclu- conclusion that the mistakes made on STS-107 sion that the mistakes mistakes mistakes mistakes mistakes mistakes mistakes made on STS-107 STS-107 STS-107 STS-107 STS-107 STS-107 STS-107 

were not isolated failures, but rather were were not isolated isolated isolated isolated isolated isolated isolated isolated failures, failures, failures, failures, failures, failures, failures, failures, but rather were 

indicative of systemic fl aws that existed indicative indicative indicative indicative indicative indicative indicative of systemic systemic systemic systemic systemic systemic systemic flaws that existed existed existed existed existed existed existed 

prior to the accident. The Diaz Team be- prior to the accident. accident. accident. accident. accident. accident. accident. The Diaz Team believes that some of these systemic fl aws exist beyond the Shuttle lieves that some of these systemic systemic systemic systemic systemic systemic systemic systemic systemic systemic systemic systemic flaws exist beyond the Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle 

Program. It was our determination that nearly half of the CAIB Program. Program. Program. Program. Program. Program. Program. Program. Program. Program. Program. It was our determination determination determination determination determination determination determination determination determination determination determination that nearly half of the CAIB 

R-O-Fs have bearing throughout the Agency. R-O-Fs have bearing throughout the Agency. 

All the selected R-O-Fs were compiled and analyzed in what All the selected selected selected selected selected selected selected selected selected selected selected selected R-O-Fs were compiled compiled compiled compiled compiled compiled compiled compiled compiled compiled compiled compiled and analyzed analyzed analyzed analyzed analyzed analyzed analyzed analyzed analyzed analyzed analyzed analyzed in what 

the Team called the CAIB Agency-wide Action Matrix, or Diaz the Team called the CAIB Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Action Matrix, Matrix, Matrix, Matrix, Matrix, Matrix, Matrix, Matrix, Matrix, Matrix, Matrix, or Diaz 

Team Matrix. We felt it was very important to release an early Team Matrix. Matrix. Matrix. Matrix. Matrix. Matrix. Matrix. Matrix. Matrix. Matrix. Matrix. We felt it was very important important important important important important important important important important important to release release release release release release release release release release release an early 

draft of the matrix to facilitate discussions within NASA. In draft of the matrix to facilitate facilitate facilitate facilitate facilitate facilitate facilitate facilitate facilitate facilitate facilitate discussions discussions discussions discussions discussions discussions discussions discussions discussions discussions discussions within NASA. In 

response, there were many inputs from NASA employees and response, response, response, response, response, response, response, response, response, response, response, there were many inputs from NASA employees employees employees employees employees employees employees employees employees employees employees and 

contractors during Safety and Mission Success Week, November contractors contractors contractors contractors contractors contractors contractors contractors contractors contractors contractors contractors during Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Success Success Success Success Success Success Success Success Success Success Success Success Week, November November November November November November November November November November November November 

17 – 21, 2003. The message from this activity is clear. Individu- 17 – 21, 2003. The message message message message message message message message message message from this activity activity activity activity activity activity activity activity activity activity is clear. Individu- Individu- Individu- Individu- Individu- Individu- Individu- Individu- Individu- Individuals in the NASA workforce state that some of the same practices als in the NASA workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce state that some of the same practices practices practices practices practices practices practices practices practices practices practices practices 

identifi ed by the CAIB are evident throughout the Agency. identified by the CAIB are evident throughout the Agency.

If NASA is to avoid another day like February 1, 2003, we must If NASA is to avoid another another another another another another another another another another another day like February February February February February February February February February February February 1, 2003, we must 

meet our mission objectives safely and renew our commitment meet our mission mission mission mission mission mission mission mission mission mission mission objectives objectives objectives objectives objectives objectives objectives objectives objectives objectives objectives safely and renew our commitment commitment commitment commitment commitment commitment commitment commitment commitment commitment commitment 

to excellence. In order to do this, we must identify corrective to excellence. excellence. excellence. excellence. excellence. excellence. excellence. excellence. excellence. excellence. excellence. excellence. In order to do this, we must identify identify identify identify identify identify identify identify identify identify identify identify corrective corrective corrective corrective corrective corrective corrective corrective corrective corrective corrective corrective 

actions for each of the causes of the accident, and then imple- actions actions actions actions actions actions actions actions actions actions actions for each of the causes of the accident, accident, accident, accident, accident, accident, accident, accident, accident, accident, accident, and then implement them fully and effectively. The CAIB Report should serve ment them fully and effectively fectively fectively fectively fectively fectively fectively fectively fectively fectively fectively fectively. The CAIB Report should serve 

as a catalyst for change in the way all of us perform our work. It as a catalyst catalyst catalyst catalyst catalyst catalyst catalyst catalyst catalyst catalyst catalyst for change in the way all of us perform perform perform perform perform perform perform perform perform perform perform our work. It 

should prompt a renewed understanding of our shared purpose. should prompt a renewed renewed renewed renewed renewed renewed renewed renewed renewed renewed renewed renewed understanding understanding understanding understanding understanding understanding understanding understanding understanding understanding understanding understanding of our shared purpose. purpose. purpose. purpose. purpose. purpose. purpose. purpose. purpose. purpose. purpose. purpose. 

Each member of this Team has recognized these high stakes and Each member of this Team has recognized recognized recognized recognized recognized recognized recognized recognized recognized recognized recognized these high stakes and 

has dedicated his or her efforts to that end. The signatures on has dedicated dedicated dedicated dedicated dedicated dedicated dedicated dedicated dedicated dedicated dedicated dedicated his or her efforts to that end. The signatures signatures signatures signatures signatures signatures signatures signatures signatures signatures signatures signatures on 

this Report and the participation of each member of the NASA this Report and the participation participation participation participation participation participation participation participation participation participation participation of each member of the NASA

leadership team at NASA Headquarters as well as at each of the leadership leadership leadership leadership leadership leadership leadership leadership leadership leadership leadership team at NASA Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters as well as at each of the 

NASA fi eld Centers are a refl ection of our joint commitment to NASA field Centers Centers Centers Centers Centers Centers Centers Centers Centers Centers Centers Centers are a reflection of our joint commitment commitment commitment commitment commitment commitment commitment commitment commitment commitment commitment commitment to 

NASAʼs future. NASAʼs future.

Dr. Ghassem Asrar Dr. Ghassem Asrar

Associate Administrator Associate Administrator

for Earth Science

NASA Headquarters NASA Headquarters

Mr. Scott Hubbard Mr. Scott Hubbard

Director, Director,

Ames Research Center

Mr. Jim Kennedy Mr. Jim Kennedy

Director, Director,

Kennedy Space Center

Dr. Julian Earls Dr. Julian Earls

Director, Director,

Glenn Research Center

Ms. Vicki Novak Ms. Vicki Novak

Assistant Administrator Assistant Administrator

for Human Resources

NASA Headquarters NASA Headquarters

PREFACE

Mr. Al Diaz Mr. Al Diaz

Director, Goddard Director, Goddard 

Space Flight Center

and Team Lead and Team Lead
2

ACKNOWLEDGEMENTS CKNOWLEDGEMENTS

The Diaz Team would like to thank each Center Director and each NASA Head- The Diaz Team would like to thank each Center Director Director Director Director Director Director Director Director Director Director Director Director Director and each NASA Headquarters Associate and Assistant Administrator and their staff for their support and quarters quarters quarters quarters quarters quarters quarters quarters quarters quarters quarters quarters quarters quarters Associate Associate Associate Associate Associate Associate Associate Associate Associate Associate Associate Associate Associate Associate and Assistant Assistant Assistant Assistant Assistant Assistant Assistant Assistant Assistant Assistant Assistant Assistant Assistant Assistant Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator and their staff for their support support support support support support support support support support support support support support and 

valuable feedback. In addition, our sincere thanks go to each NASA employee and valuable valuable valuable valuable valuable valuable valuable valuable valuable valuable valuable valuable valuable feedback. feedback. feedback. feedback. feedback. feedback. feedback. feedback. feedback. feedback. feedback. feedback. feedback. In addition, addition, addition, addition, addition, addition, addition, addition, addition, addition, addition, addition, addition, our sincere sincere sincere sincere sincere sincere sincere sincere sincere sincere sincere sincere sincere thanks go to each NASA employee employee employee employee employee employee employee employee employee employee employee employee employee and 

contractor who participated in discussions and provided their insights especially contractor contractor contractor contractor contractor contractor contractor contractor contractor contractor contractor contractor contractor contractor who participated participated participated participated participated participated participated participated participated participated participated participated participated participated in discussions discussions discussions discussions discussions discussions discussions discussions discussions discussions discussions discussions discussions discussions and provided provided provided provided provided provided provided provided provided provided provided provided provided provided their insights insights insights insights insights insights insights insights insights insights insights insights insights insights especially especially especially especially especially especially especially especially especially especially especially especially especially especially 

through participation in Safety and Mission Success Week, November 17 – 21, through through through through through through through through through through through through through participation participation participation participation participation participation participation participation participation participation participation participation participation in Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Success Success Success Success Success Success Success Success Success Success Success Success Success Week, November November November November November November November November November November November November November 17 – 21, 

2003. Those contributions were of great value, and they have been incorporated 2003. Those contributions contributions contributions contributions contributions contributions contributions contributions contributions contributions contributions contributions contributions were of great value, and they have been incorporated incorporated incorporated incorporated incorporated incorporated incorporated incorporated incorporated incorporated incorporated incorporated incorporated 

into this fi nal Report. In that respect, therefore, this is their Report, as well as into this final Report. Report. Report. Report. Report. Report. Report. Report. Report. Report. Report. Report. Report. Report. In that respect, respect, respect, respect, respect, respect, respect, respect, respect, respect, respect, respect, respect, respect, therefore, therefore, therefore, therefore, therefore, therefore, therefore, therefore, therefore, therefore, therefore, therefore, therefore, therefore, this is their Report, Report, Report, Report, Report, Report, Report, Report, Report, Report, Report, Report, Report, Report, as well as 

ours.

We would like to give special acknowledgement to the One NASA Team led by We would like to give special special special special special special special special special special special special special acknowledgement acknowledgement acknowledgement acknowledgement acknowledgement acknowledgement acknowledgement acknowledgement acknowledgement acknowledgement acknowledgement acknowledgement acknowledgement to the One NASA Team led by 

Mr. Johnny Stephenson. Their energy and dedication to NASA was instrumental Mr. Johnny Stephenson. Stephenson. Stephenson. Stephenson. Stephenson. Stephenson. Stephenson. Stephenson. Stephenson. Stephenson. Stephenson. Stephenson. Stephenson. Stephenson. Their energy and dedication dedication dedication dedication dedication dedication dedication dedication dedication dedication dedication dedication dedication dedication to NASA was instrumental instrumental instrumental instrumental instrumental instrumental instrumental instrumental instrumental instrumental instrumental instrumental instrumental instrumental 

in achieving the success of Safety and Mission Success Week. in achieving the success of Safety and Mission Success Week.

While it is diffi cult to acknowledge each individual that made a signifi cant con- While it is difficult to acknowledge acknowledge acknowledge acknowledge acknowledge acknowledge acknowledge acknowledge acknowledge acknowledge acknowledge acknowledge acknowledge each individual individual individual individual individual individual individual individual individual individual individual individual individual that made a signifi signicant contribution to the development of this Report, there are two individuals that deserve tribution tribution tribution tribution tribution tribution tribution tribution tribution tribution tribution tribution tribution to the development development development development development development development development development development development development development of this Report, Report, Report, Report, Report, Report, Report, Report, Report, Report, Report, Report, Report, there are two individuals individuals individuals individuals individuals individuals individuals individuals individuals individuals individuals individuals individuals that deserve deserve deserve deserve deserve deserve deserve deserve deserve deserve deserve deserve deserve 

special recognition. The Team would like to thank Ms. Judy Bruner, Assistant special special special special special special special special special special special special special special recognition. recognition. recognition. recognition. recognition. recognition. recognition. recognition. recognition. recognition. recognition. recognition. recognition. recognition. The Team would like to thank Ms. Judy Bruner, Assistant Assistant Assistant Assistant Assistant Assistant Assistant Assistant Assistant Assistant Assistant Assistant Assistant Assistant 

Director for Safety and Security, NASAʼs Goddard Space Flight Center, for Director Director Director Director Director Director Director Director Director Director Director Director Director for Safety and Security Security Security Security Security Security Security Security Security Security Security Security Security, NASAʼs Goddard Goddard Goddard Goddard Goddard Goddard Goddard Goddard Goddard Goddard Goddard Goddard Goddard Space Flight Center, for 

her steadfast commitment and dedication to the successful development of this her steadfast steadfast steadfast steadfast steadfast steadfast steadfast steadfast steadfast steadfast steadfast steadfast steadfast steadfast commitment commitment commitment commitment commitment commitment commitment commitment commitment commitment commitment commitment commitment commitment and dedication dedication dedication dedication dedication dedication dedication dedication dedication dedication dedication dedication dedication dedication to the successful successful successful successful successful successful successful successful successful successful successful successful successful successful development development development development development development development development development development development development development development of this 

Report and for her personal contributions to its content. We would also like to Report and for her personal personal personal personal personal personal personal personal personal personal personal personal personal contributions contributions contributions contributions contributions contributions contributions contributions contributions contributions contributions contributions contributions to its content. content. content. content. content. content. content. content. content. content. content. content. content. We would also like to 

recognize the invaluable contributions of Mr. Kevin Mabie, Valador Inc., for his recognize recognize recognize recognize recognize recognize recognize recognize recognize recognize recognize recognize recognize recognize the invaluable invaluable invaluable invaluable invaluable invaluable invaluable invaluable invaluable invaluable invaluable invaluable invaluable invaluable contributions contributions contributions contributions contributions contributions contributions contributions contributions contributions contributions contributions contributions contributions of Mr. Kevin Mabie, Valador Inc., for his 

contributions both in writing as well as producing this Report.

DEDICATION EDICATION

The Diaz Team would like to dedicate this Report and the efforts involved in the The Diaz Team would like to dedicate dedicate dedicate dedicate dedicate dedicate dedicate dedicate dedicate dedicate dedicate dedicate dedicate dedicate this Report and the efforts involved involved involved involved involved involved involved involved involved involved involved involved involved involved in the 

development of it to the memory of the crew of the Space Shuttle development development development development development development development development development development development of it to the memory of the crew of the Space Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Columbia. It 

was their bravery that inspired us to make a difference in NASAʼs future on their was their bravery bravery bravery bravery bravery bravery bravery bravery bravery bravery bravery bravery bravery bravery that inspired inspired inspired inspired inspired inspired inspired inspired inspired inspired inspired inspired inspired inspired us to make a difference ference ference ference ference ference ference ference ference ference ference ference ference ference in NASAʼs future on their 

behalf.

Mr. Al Diaz Mr. Al Diaz

Director, Goddard Space Flight Center Director, Goddard Space Flight Center

and Team Lead and Team Lead
3

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Acknowledgements and Dedication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

1.0 Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

1.2 Leadership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

1.3 Learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

1.4 Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

1.5 Processes and Rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

1.6 Technical Capabilities Technical Capabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

1.7 Organizational Structure Organizational Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

1.8 Risk Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

1.9 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

1.10 Next Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

2.0 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

2.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

2.2 The Team and Its Charter The Team and Its Charter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

2.3 R-O-F Categories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

2.4 Team Discussions Team Discussions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

2.5 Safety and Mission Success Week Safety and Mission Success Week . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

2.6 Report Layout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

3.0 Leadership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

3.2 Category R-O-F Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

3.3 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

4.0 Learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

4.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

4.2 Category R-O-F Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

4.3 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

5.0 Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

5.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

5.2 Category R-O-F Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

5.3 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

6.0 Processes and Rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

6.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

6.2 Category R-O-F Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

6.3 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

7.0 Technical Capabilities Technical Capabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

7.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

7.2 Category R-O-F Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

7.3 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

8.0 Organizational Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

8.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

8.2 Category R-O-F Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

8.3 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

9.0 Risk Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

9.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

9.2 Category R-O-F Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

9.3 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

10.0 Summary and Next Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

10.1 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

10.2 Next Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-1

Appendix A Appendix A The Diaz Team Matrix The Diaz Team Matrix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-1

Appendix B Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-1
4

List of Tables List of Tables

Table 1. Table 1. The Physical Cause and Organizational Cause of the Columbia accident as determined by the CAIB. The Physical Cause and Organizational Cause of the Columbia accident as determined by the CAIB. . . . . . . . 5

Table 2. Table 2. The Diaz Team developed one goal for Leadership. The Diaz Team developed one goal for Leadership. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Table 3. Table 3. The Diaz Team developed one goal for Learning. The Diaz Team developed one goal for Learning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Table 4. Table 4. The Diaz Team developed one goal for Communication. The Diaz Team developed one goal for Communication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Table 5. Table 5. The Diaz Team developed one goal for Processes and Rules. The Diaz Team developed one goal for Processes and Rules. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Table 6. Table 6. The Diaz Team developed one goal for Technical Capabilities. The Diaz Team developed one goal for Technical Capabilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Table 7. Table 7. The Diaz Team developed one goal for Organizational Structure. The Diaz Team developed one goal for Organizational Structure. . . . . . . . . . . . . . . . . . . . . . . . . . 15

Table 8. Table 8. The Diaz Team developed one goal for Risk Management. The Diaz Team developed one goal for Risk Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Table 9. Table 9. Organizing the R-O-Fs – the seven categories and their defi nitions. Organizing the R-O-Fs – the seven categories and their definitions. . . . . . . . . . . . . . . . . . . . . . . . . 20

Table 10. Table 10. The Diaz Team developed one goal for Leadership. The Diaz Team developed one goal for Leadership. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Table 11. Table 11. The Diaz Team determined that three Observations, and 14 Findings could be included The Diaz Team determined that three Observations, and 14 Findings could be included 

in the Leadership Category resulting in seven actions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Table 12. Table 12. The Diaz Team developed one goal for Learning. The Diaz Team developed one goal for Learning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Table 13. Table 13. The Diaz Team determined that one Recommendation and four Findings could be included The Diaz Team determined that one Recommendation and four Findings could be included 

in the Learning Category resulting in three actions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Table 14. Table 14. The Diaz Team developed one goal for Communication. The Diaz Team developed one goal for Communication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Table 15. Table 15. The Diaz Team determined that fi ve Findings could be included in the Communication Category The Diaz Team determined that five Findings could be included in the Communication Category 

resulting in two actions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Table 16. Table 16. The Diaz Team developed one goal for Processes and Rules. The Diaz Team developed one goal for Processes and Rules. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Table 17. Table 17. The Diaz Team determined that two Recommendations, three Observations, and six Findings The Diaz Team determined that two Recommendations, three Observations, and six Findings 

could be included in the Processes & Rules Category resulting in seven actions. . . . . . . . . . . . . . . . . . 36

Table 18. Table 18. The Diaz Team developed one goal for Technical Capabilities. The Diaz Team developed one goal for Technical Capabilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Table 19. Table 19. The Diaz Team determined that three Recommendations, and 13 Findings could be included The Diaz Team determined that three Recommendations, and 13 Findings could be included 

in the Technical Capabilities Category resulting in six actions. in the Technical Capabilities Category resulting in six actions. . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Table 20. Table 20. The Diaz Team developed one goal for Organizational Structure. The Diaz Team developed one goal for Organizational Structure. . . . . . . . . . . . . . . . . . . . . . . . . . 44

Table 21. Table 21. The Diaz Team determined that three Recommendations and 10 Findings could be included The Diaz Team determined that three Recommendations and 10 Findings could be included 

in the Organizational Structure Category, resulting in four actions. in the Organizational Structure Category, resulting in four actions. . . . . . . . . . . . . . . . . . . . . . . . . . 45

Table 22. Table 22. The Diaz Team developed one goal for Risk Management. The Diaz Team developed one goal for Risk Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Table 23. Table 23. The Diaz Team determined that four Recommendations, two Observations, and 12 Findings The Diaz Team determined that four Recommendations, two Observations, and 12 Findings 

could be included in the Risk Management Category resulting in 11 actions. . . . . . . . . . . . . . . . . . . . 49

Table 24. Table 24. Diaz Team Goals Diaz Team Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

List of Figures

Figure 1. The Diaz Team process required wide acceptance and dissemination of all determinations. The Diaz Team process required wide acceptance and dissemination of all determinations. . . . . . . . . . . . . . 6

Figure 2. Diaz Team determination of broadly applicable R-O-Fs for the Agency. Diaz Team determination of broadly applicable R-O-Fs for the Agency.. . . . . . . . . . . . . . . . . . . . . . . . 7

Figure 3. Seven NASA organizations have actions resulting from the Diaz determinations. Seven NASA organizations have actions resulting from the Diaz determinations. . . . . . . . . . . . . . . . . . . 7

Figure 4. Overlap currently exists between the Implementation Plans for different or ferent organizations. ganizations. 

NASA Headquarters must coordinate when duplications of efforts might occur. NASA Headquarters must coordinate when duplications of efforts might occur. . . . . . . . . . . . . . . . . . . 8

Figure 5. The Diaz Team categorized the CAIB R-O-Fs into seven distinct categories, each of which The Diaz Team categorized the CAIB R-O-Fs into seven distinct categories, each of which 

has a major premise. Each category is fully addressed in the body of the Report. . . . . . . . . . . . . . . . . . . 9
5

1.1 INTRODUCTION NTRODUCTION

The Space Shuttle fl eet has been grounded since the The Space Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle fleet has been grounded grounded grounded grounded grounded grounded grounded grounded grounded grounded since the Columbia

accident. As a result, “Return to Flight” has become not just a accident. accident. accident. accident. accident. accident. accident. accident. accident. accident. accident. As a result, result, result, result, result, result, result, result, result, result, result, “Return “Return “Return “Return “Return “Return “Return “Return “Return “Return “Return to Flight” Flight” Flight” Flight” Flight” Flight” Flight” Flight” Flight” Flight” Flight” has become not just a 

phrase but a program, and the goal of virtually everyone asso- phrase but a program, program, program, program, program, program, program, program, program, program, program, program, and the goal of virtually virtually virtually virtually virtually virtually virtually virtually virtually virtually virtually virtually everyone everyone everyone everyone everyone everyone everyone everyone everyone everyone everyone everyone associated with NASA. Even those who are not affi liated with the ciated with NASA. Even those who are not affiliated with the 

Shuttle Program are looking forward to the safe and successful Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Program Program Program Program Program Program Program Program Program Program Program Program are looking looking looking looking looking looking looking looking looking looking looking looking forward forward forward forward forward forward forward forward forward forward forward forward to the safe and successful successful successful successful successful successful successful successful successful successful successful successful 

completion of the next Shuttle mission. In this recovery completion completion completion completion completion completion completion completion completion completion completion of the next Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle mission. mission. mission. mission. mission. mission. mission. mission. mission. mission. mission. In this recovery recovery recovery recovery recovery recovery recovery recovery recovery recovery recovery process, process, process, process, process, process, process, process, process, process, process, process, 

NASA will be guided by the Report of the Columbia Accident NASA will be guided by the Report of the Columbia Columbia Columbia Columbia Columbia Columbia Columbia Columbia Columbia Columbia Columbia Accident Accident Accident Accident Accident Accident Accident Accident Accident Accident Accident 

Investigation Board (CAIB).

The CAIB was an investigating body, convened by NASA Ad- The CAIB was an investigating investigating investigating investigating investigating investigating investigating investigating investigating investigating investigating investigating body, convened convened convened convened convened convened convened convened convened convened convened convened by NASA Administrator OʼKeefe the day of the ministrator ministrator ministrator ministrator ministrator ministrator OʼKeefe OʼKeefe OʼKeefe OʼKeefe OʼKeefe OʼKeefe the day of the Columbia accident, according accident, according 

to procedures established after the loss of Shuttle to procedures procedures procedures procedures procedures procedures procedures procedures procedures established established established established established established established established established after the loss of Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Challenger. 

The 13 Board Members and more than 120 staff members ex- The 13 Board Members Members Members Members Members Members Members Members Members Members Members and more than 120 staff members members members members members members members members members members members examined more than 30,000 documents, conducted more than amined more than 30,000 documents, documents, documents, documents, documents, documents, documents, documents, documents, documents, documents, conducted conducted conducted conducted conducted conducted conducted conducted conducted conducted conducted more than 

200 formal interviews, heard testimony from dozens of expert 200 formal interviews, interviews, interviews, interviews, interviews, interviews, interviews, interviews, interviews, interviews, interviews, heard testimony testimony testimony testimony testimony testimony testimony testimony testimony testimony testimony from dozens of expert 

witnesses, and reviewed more than 3,000 public inputs. While witnesses, witnesses, witnesses, witnesses, witnesses, witnesses, witnesses, witnesses, witnesses, witnesses, witnesses, and reviewed reviewed reviewed reviewed reviewed reviewed reviewed reviewed reviewed reviewed reviewed more than 3,000 public inputs. inputs. inputs. inputs. inputs. inputs. inputs. inputs. inputs. inputs. inputs. While 

the CAIB maintained strict independence from NASA in its de- the CAIB maintained maintained maintained maintained maintained maintained maintained maintained maintained maintained maintained maintained strict independence independence independence independence independence independence independence independence independence independence independence independence from NASA in its deliberations and analysis, it did receive technical support from ap- liberations liberations liberations liberations liberations liberations liberations liberations liberations liberations liberations and analysis, analysis, analysis, analysis, analysis, analysis, analysis, analysis, analysis, analysis, analysis, it did receive receive receive receive receive receive receive receive receive receive receive technical technical technical technical technical technical technical technical technical technical technical support support support support support support support support support support support from approximately 400 NASA engineers. In addition, more than 25,000 proximately proximately proximately proximately proximately proximately proximately proximately proximately proximately proximately proximately 400 NASA engineers. engineers. engineers. engineers. engineers. engineers. engineers. engineers. engineers. engineers. engineers. engineers. In addition, addition, addition, addition, addition, addition, addition, addition, addition, addition, addition, addition, more than 25,000 

searchers helped retrieve the Columbia debris. 

The CAIB ultimately drew a distinction between the physical The CAIB ultimately ultimately ultimately ultimately ultimately ultimately ultimately ultimately ultimately ultimately ultimately drew a distinction distinction distinction distinction distinction distinction distinction distinction distinction distinction distinction between between between between between between between between between between between the physical physical physical physical physical physical physical physical physical physical physical 

and organizational causes of the accident, and the Board Report and organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational causes of the accident, accident, accident, accident, accident, accident, accident, accident, accident, accident, accident, and the Board Report 

accordingly included separate causal statements. The physical accordingly accordingly accordingly accordingly accordingly accordingly accordingly accordingly accordingly accordingly accordingly accordingly included included included included included included included included included included included included separate separate separate separate separate separate separate separate separate separate separate separate causal statements. statements. statements. statements. statements. statements. statements. statements. statements. statements. statements. statements. The physical physical physical physical physical physical physical physical physical physical physical physical 

cause statement documented the sequence of events on Shuttle cause statement statement statement statement statement statement statement statement statement statement statement documented documented documented documented documented documented documented documented documented documented documented the sequence sequence sequence sequence sequence sequence sequence sequence sequence sequence sequence of events on Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle 

Mission STS-107 that led to the breakup of the Orbiter. A variety Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission STS-107 STS-107 STS-107 STS-107 STS-107 STS-107 STS-107 STS-107 STS-107 STS-107 STS-107 STS-107 that led to the breakup breakup breakup breakup breakup breakup breakup breakup breakup breakup breakup breakup of the Orbiter Orbiter Orbiter Orbiter Orbiter Orbiter Orbiter Orbiter Orbiter Orbiter Orbiter Orbiter. A variety variety variety variety variety variety variety variety variety variety variety variety 

of separate analyses, each based on its own extensive body of ev- of separate separate separate separate separate separate separate separate separate separate separate analyses, analyses, analyses, analyses, analyses, analyses, analyses, analyses, analyses, analyses, analyses, each based on its own extensive extensive extensive extensive extensive extensive extensive extensive extensive extensive extensive body of evidence, all pointed to the sequence found in that causal statement idence, idence, idence, idence, idence, idence, idence, idence, idence, idence, idence, idence, all pointed pointed pointed pointed pointed pointed pointed pointed pointed pointed pointed pointed to the sequence sequence sequence sequence sequence sequence sequence sequence sequence sequence sequence sequence found in that causal statement statement statement statement statement statement statement statement statement statement statement statement 

of the CAIB Report. The organizational cause statement spells of the CAIB Report. Report. Report. Report. Report. Report. Report. Report. Report. Report. Report. The organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational cause statement statement statement statement statement statement statement statement statement statement statement spells 

out what might be considered the precursors to the physical out what might be considered considered considered considered considered considered considered considered considered considered considered considered the precursors precursors precursors precursors precursors precursors precursors precursors precursors precursors precursors precursors to the physical physical physical physical physical physical physical physical physical physical physical physical 

cause: the conditions that allowed the technical failures to take cause: the conditions conditions conditions conditions conditions conditions conditions conditions conditions conditions conditions that allowed allowed allowed allowed allowed allowed allowed allowed allowed allowed allowed the technical technical technical technical technical technical technical technical technical technical technical failures failures failures failures failures failures failures failures failures failures failures to take 

place and eventually lead to the accident. Table 1 contains the place and eventually eventually eventually eventually eventually eventually eventually eventually eventually eventually eventually eventually lead to the accident. accident. accident. accident. accident. accident. accident. accident. accident. accident. accident. accident. Table 1 contains contains contains contains contains contains contains contains contains contains contains contains the 

Physical Cause Statement and Organizational Cause Statement. Physical Cause Statement and Organizational Cause Statement.

Of the 29 recommendations in the Report of the CAIB, 15 are Of the 29 recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations in the Report of the CAIB, 15 are 

designated as “RTF” signifying that they must be completed be- designated designated designated designated designated designated designated designated designated designated designated as “RTF” signifying signifying signifying signifying signifying signifying signifying signifying signifying signifying signifying that they must be completed completed completed completed completed completed completed completed completed completed completed before the Space Shuttle can “Return to Flight.” But the CAIB rec- fore the Space Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle can “Return “Return “Return “Return “Return “Return “Return “Return “Return “Return “Return “Return to Flight.” Flight.” Flight.” Flight.” Flight.” Flight.” Flight.” Flight.” Flight.” Flight.” Flight.” Flight.” But the CAIB recognized, and NASA Administrator Sean OʼKeefe has concurred, ognized, ognized, ognized, ognized, ognized, ognized, ognized, ognized, ognized, ognized, ognized, and NASAAdministrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Sean OʼKeefe OʼKeefe OʼKeefe OʼKeefe OʼKeefe OʼKeefe OʼKeefe OʼKeefe OʼKeefe OʼKeefe OʼKeefe has concurred, concurred, concurred, concurred, concurred, concurred, concurred, concurred, concurred, concurred, concurred, 

that the problems at NASA extend beyond what is addressed in that the problems problems problems problems problems problems problems problems problems problems problems problems at NASA extend beyond what is addressed addressed addressed addressed addressed addressed addressed addressed addressed addressed addressed addressed in 

those 15 recommendations. That is why the CAIB Report con- those 15 recommendations. recommendations. recommendations. recommendations. recommendations. recommendations. recommendations. recommendations. recommendations. recommendations. recommendations. That is why the CAIB Report contains 14 more recommendations, as well as 27 observations and tains 14 more recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, as well as 27 observations observations observations observations observations observations observations observations observations observations observations and 

137 fi ndings. Most of these are specifi c to the long-term opera- 137 findings. ndings. ndings. ndings. ndings. ndings. ndings. ndings. ndings. ndings. Most of these are specifi specic to the long-term long-term long-term long-term long-term long-term long-term long-term long-term long-term operation of the Human Space Flight Program, but the Administrator tion of the Human Space Flight Program, Program, Program, Program, Program, Program, Program, Program, Program, Program, Program, but the Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator 

recognized that a substantial number might be applied across the recognized recognized recognized recognized recognized recognized recognized recognized recognized recognized recognized recognized that a substantial substantial substantial substantial substantial substantial substantial substantial substantial substantial substantial substantial number might be applied applied applied applied applied applied applied applied applied applied applied applied across the 

Agency. Taking these necessary prescribed steps will ensure, Agency. Taking these necessary necessary necessary necessary necessary necessary necessary necessary necessary necessary necessary prescribed prescribed prescribed prescribed prescribed prescribed prescribed prescribed prescribed prescribed prescribed steps will ensure, ensure, ensure, ensure, ensure, ensure, ensure, ensure, ensure, ensure, ensure, 

in the opinion of the Diaz Team, that not only will the Shuttle in the opinion opinion opinion opinion opinion opinion opinion opinion opinion opinion opinion opinion of the Diaz Team, that not only will the Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle 

“Return to Flight,” but all of NASA will renew its commitment “Return “Return “Return “Return “Return “Return “Return “Return “Return “Return “Return to Flight,” Flight,” Flight,” Flight,” Flight,” Flight,” Flight,” Flight,” Flight,” Flight,” Flight,” but all of NASA will renew its commitment commitment commitment commitment commitment commitment commitment commitment commitment commitment commitment 

to excellence.

Which are the recommendations, observations, and fi ndings (R- Which are the recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, observations, observations, observations, observations, observations, observations, observations, observations, observations, observations, observations, and findings (RO-Fs) that have this broad applicability Agency-wide? That is O-Fs) that have this broad applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability Agency-wide? Agency-wide? Agency-wide? Agency-wide? Agency-wide? Agency-wide? Agency-wide? Agency-wide? Agency-wide? Agency-wide? Agency-wide? Agency-wide? That is 

the question that NASAʼs Administrator put to a team comprised the question question question question question question question question question question question that NASAʼs Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator put to a team comprised comprised comprised comprised comprised comprised comprised comprised comprised comprised comprised 

1.0 EXECUTIVE SUMMARY

The Diaz Team’s Charter:

• Identify those R-O-Fs from the CAIB Report that might apply across the Agency.

• Identify a set of actions and suggested leadership for those actions.

• Include the One NASA* Team in all activities.

• Summarize results in a Report to the NASA Deputy Administrator.

Table 1. The Physical Cause and Organizational Cause of the Columbia accident as determined by the CAIB.

Physical Cause and Organizational Cause

CAIB Report Chapter 3, p49:

The physical cause of the loss of The physical physical physical physical physical cause of the loss of Columbia and its crew was a breach in the Thermal Protection System on the leading edge of the and its crew was a breach in the Thermal Thermal Thermal Thermal Thermal Thermal Thermal Thermal Thermal Thermal Thermal Thermal Thermal Protection Protection Protection Protection Protection Protection Protection Protection Protection Protection Protection Protection Protection System on the leading leading leading leading leading leading leading leading leading leading leading leading leading edge of the 

left wing. The breach was initiated by a piece of insulating foam that separated from the left bipod ramp of the External Tank and 

struck the wing in the vicinity of the lower half of Reinforced Carbon-Carbon panel 8 at 81.9 seconds after launch. During re-entry, 

this breach in the Thermal Protection System allowed superheated air to penetrate the leading-edge insulation and progressively 

melt the aluminum structure of the left wing, resulting in a weakening of the structure until increasing aerodynamic forces caused 

loss of control, failure of the wing, and breakup of the Orbiter.

CAIB Report Chapter 7, p177:

The organizational causes of this accident are rooted in the Space Shuttle Program’s history and culture, including the original 

compromises that were required to gain approval for the Shuttle Program, subsequent years of resource constraints, fl uctuating uctuating 

priorities, schedule pressures, mischaracterizations of the Shuttle as operational rather than developmental, and lack of an agreed 

national vision. Cultural traits and organizational practices detrimental to safety were allowed to develop, including: reliance on 

past success as a substitute for sound engineering practices (such as testing to understand why systems were not performing 

in accordance with requirements/specifi cations); organizational barriers that prevented effective communication of critical safety in accordance with requirements/specifications); organizational barriers that prevented effective communication of critical safety 

information and stifl ed professional differences of opinion; lack of integrated management across program elements; and the information and stifled professional differences of opinion; lack of integrated management across program elements; and the 

evolution of an informal chain of command and decision-making processes that operated outside the organization’s rules.

* The One NASA effort was initiated prior to the The One NASA effort was initiated initiated initiated initiated initiated initiated prior to the Columbia accident by a group of middle managers from across the Agency. The vision of One NASA is accident accident accident accident accident accident accident accident accident accident accident accident accident by a group of middle managers managers managers managers managers managers managers managers managers managers managers managers managers from across the Agency. The vision of One NASA is 

for a more cohesive, collaborative, and less bureaucratic Agency. for a more cohesive, collaborative, and less bureaucratic Agency.
6

of members of NASAʼs Senior Leadership Council led by Mr. Al of members members members members members members members members members members members of NASAʼs Senior Leadership Leadership Leadership Leadership Leadership Leadership Leadership Leadership Leadership Leadership Leadership Council Council Council Council Council Council Council Council Council Council Council led by Mr. Al 

Diaz, Director of the Goddard Space Flight Center. It has also Diaz, Director Director Director Director Director Director Director Director Director Director Director of the Goddard Goddard Goddard Goddard Goddard Goddard Goddard Goddard Goddard Goddard Goddard Space Flight Center. It has also 

been their assignment to spell out a specifi c course of actions to been their assignment assignment assignment assignment assignment assignment assignment assignment assignment assignment assignment assignment to spell out a specifi specic course of actions actions actions actions actions actions actions actions actions actions actions actions to 

accomplish what has been called for. Other members of what has accomplish accomplish accomplish accomplish accomplish accomplish accomplish accomplish accomplish accomplish accomplish what has been called for. Other members members members members members members members members members members members of what has 

come to be called the Diaz Team include: Dr. Ghassem Asrar, come to be called the Diaz Team include: include: include: include: include: include: include: include: include: include: include: include: Dr. Ghassem Ghassem Ghassem Ghassem Ghassem Ghassem Ghassem Ghassem Ghassem Ghassem Ghassem Ghassem Asrar, 

Associate Administrator for Earth Sciences, NASA Headquar- Associate Associate Associate Associate Associate Associate Associate Associate Associate Associate Associate Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator for Earth Sciences, Sciences, Sciences, Sciences, Sciences, Sciences, Sciences, Sciences, Sciences, Sciences, Sciences, NASA Headquar Headquar Headquar Headquar Headquar Headquar Headquar Headquar Headquar Headquar Headquarters; Dr. Julian Earls, Director, Glenn Research Center; Mr. Scott ters; Dr. Julian Earls, Director Director Director Director Director Director Director Director Director Director Director Director, Glenn Research Research Research Research Research Research Research Research Research Research Research Research Center; Center; Center; Center; Center; Center; Center; Center; Center; Center; Center; Center; Mr. Scott 

Hubbard, Director, Ames Research Center; Mr. James Kennedy, Hubbard, Hubbard, Hubbard, Hubbard, Hubbard, Hubbard, Hubbard, Hubbard, Hubbard, Hubbard, Hubbard, Director Director Director Director Director Director Director Director Director Director Director, Ames Research Research Research Research Research Research Research Research Research Research Research Center; Center; Center; Center; Center; Center; Center; Center; Center; Center; Center; Mr. James Kennedy Kennedy Kennedy Kennedy Kennedy Kennedy Kennedy Kennedy Kennedy Kennedy Kennedy, 

Director, Kennedy Space Center; and Ms. Vicki Novak, Assistant Director Director Director Director Director Director Director Director Director Director Director, Kennedy Kennedy Kennedy Kennedy Kennedy Kennedy Kennedy Kennedy Kennedy Kennedy Kennedy Space Center; Center; Center; Center; Center; Center; Center; Center; Center; Center; Center; and Ms. Vicki Novak, Assistant Assistant Assistant Assistant Assistant Assistant Assistant Assistant Assistant Assistant Assistant 

Administrator for Human Resources, NASA Headquarters. Administrator for Human Resources, NASA Headquarters.

The Organizational Cause Statement in the CAIB Report The Organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational Cause Statement Statement Statement Statement Statement Statement Statement Statement Statement Statement Statement Statement in the CAIB Report 

guided the Teamʼs deliberations from the beginning. The Team, guided the Teamʼs deliberations deliberations deliberations deliberations deliberations deliberations deliberations deliberations deliberations deliberations deliberations from the beginning. beginning. beginning. beginning. beginning. beginning. beginning. beginning. beginning. beginning. beginning. The Team, 

therefore, determined that all R-O-Fs that dealt directly or in- therefore, therefore, therefore, therefore, therefore, therefore, therefore, therefore, therefore, therefore, therefore, therefore, determined determined determined determined determined determined determined determined determined determined determined determined that all R-O-Fs that dealt directly directly directly directly directly directly directly directly directly directly directly directly or indirectly with organizational behaviors that might have a bear- directly directly directly directly directly directly directly directly directly directly directly with organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational behaviors behaviors behaviors behaviors behaviors behaviors behaviors behaviors behaviors behaviors behaviors that might have a bearing on safety or mission success would be identifi ed as having ing on safety or mission mission mission mission mission mission mission mission mission mission mission mission success success success success success success success success success success success success would be identifi identifi identifi identifi identifi identifi identifi identifi identifi identifi identifi identified as having 

Agency-wide applicability. In addition, the Team has worked Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability. In addition, addition, addition, addition, addition, addition, addition, addition, addition, addition, addition, the Team has worked 

to assure that its Report would be understood and accepted by to assure that its Report would be understood understood understood understood understood understood understood understood understood understood understood and accepted accepted accepted accepted accepted accepted accepted accepted accepted accepted accepted by 

the NASA workforce. With that objective in mind, the Team the NASA workforce. workforce. workforce. workforce. workforce. workforce. workforce. workforce. workforce. workforce. workforce. workforce. With that objective objective objective objective objective objective objective objective objective objective objective objective in mind, the Team 

established a work plan at its fi rst meeting in September 2003 established established established established established established established established established established established a work plan at its first meeting meeting meeting meeting meeting meeting meeting meeting meeting meeting meeting in September September September September September September September September September September September 2003 

that allowed for extensive Agency review of all that the Team that allowed allowed allowed allowed allowed allowed allowed allowed allowed allowed allowed allowed for extensive extensive extensive extensive extensive extensive extensive extensive extensive extensive extensive extensive Agency review of all that the Team 

produced. Figure 1 outlines that plan. The fi rst product the produced. produced. produced. produced. produced. produced. produced. produced. produced. produced. produced. Figure 1 outlines outlines outlines outlines outlines outlines outlines outlines outlines outlines outlines that plan. The first product product product product product product product product product product product the 

Diaz Team developed and distributed was the CAIB Agency Diaz Team developed developed developed developed developed developed developed developed developed developed developed developed and distributed distributed distributed distributed distributed distributed distributed distributed distributed distributed distributed distributed was the CAIB Agency 

Wide Action Matrix, hereafter referred to as the Diaz Team Wide Action Matrix, Matrix, Matrix, Matrix, Matrix, Matrix, Matrix, Matrix, Matrix, Matrix, Matrix, hereafter hereafter hereafter hereafter hereafter hereafter hereafter hereafter hereafter hereafter hereafter referred referred referred referred referred referred referred referred referred referred referred to as the Diaz Team 

Matrix, which is included as an appendix in the Report. The Matrix, Matrix, Matrix, Matrix, Matrix, Matrix, Matrix, Matrix, Matrix, Matrix, Matrix, which is included included included included included included included included included included included as an appendix appendix appendix appendix appendix appendix appendix appendix appendix appendix appendix in the Report. Report. Report. Report. Report. Report. Report. Report. Report. Report. Report. The 

Diaz Team Matrix is in a tabular format that identifi es which Diaz Team Matrix is in a tabular tabular tabular tabular tabular tabular tabular tabular tabular tabular tabular format that identifi identifi identifi identifi identifi identifi identifi identifi identifi identifi identifies which 

R-O-Fs are broadly applicable. The entry for each R-O-F pro- R-O-Fs are broadly broadly broadly broadly broadly broadly broadly broadly broadly broadly broadly applicable. applicable. applicable. applicable. applicable. applicable. applicable. applicable. applicable. applicable. applicable. The entry for each R-O-F provides a rationale for including it and recommends a set of actions vides a rationale rationale rationale rationale rationale rationale rationale rationale rationale rationale rationale rationale for including including including including including including including including including including including including it and recommends recommends recommends recommends recommends recommends recommends recommends recommends recommends recommends recommends a set of actions actions actions actions actions actions actions actions actions actions actions actions 

to address it. The Diaz Team Matrix went through a series of to address address address address address address address address address address address it. The Diaz Team Matrix went through through through through through through through through through through through a series of 

reviews, fi rst by Diaz Team members, and then by NASA senior reviews, reviews, reviews, reviews, reviews, reviews, reviews, reviews, reviews, reviews, reviews, reviews, first by Diaz Team members, members, members, members, members, members, members, members, members, members, members, members, and then by NASA senior 

management. To facilitate discussions during Safety and Mis- management. management. management. management. management. management. management. management. management. management. management. To facilitate facilitate facilitate facilitate facilitate facilitate facilitate facilitate facilitate facilitate facilitate discussions discussions discussions discussions discussions discussions discussions discussions discussions discussions discussions during Safety and Mission Success Week, the matrix was then distributed to more than sion Success Success Success Success Success Success Success Success Success Success Success Success Week, the matrix was then distributed distributed distributed distributed distributed distributed distributed distributed distributed distributed distributed distributed to more than 

65,000 members of the NASA workforce, both civil service and 65,000 members members members members members members members members members members members of the NASA workforce, workforce, workforce, workforce, workforce, workforce, workforce, workforce, workforce, workforce, workforce, both civil service service service service service service service service service service service and 

contractor employees. The resulting feedback was outstanding contractor contractor contractor contractor contractor contractor contractor contractor contractor contractor employees. employees. employees. employees. employees. employees. employees. employees. employees. employees. The resulting resulting resulting resulting resulting resulting resulting resulting resulting resulting feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback was outstanding outstanding outstanding outstanding outstanding outstanding outstanding outstanding outstanding outstanding 

in both quantity and quality. A thorough review of those many in both quantity quantity quantity quantity quantity quantity quantity quantity quantity quantity and quality quality quality quality quality quality quality quality quality quality. A thorough thorough thorough thorough thorough thorough thorough thorough thorough thorough review of those many 

thoughtful comments showed that an overwhelming majority thoughtful thoughtful thoughtful thoughtful thoughtful thoughtful thoughtful thoughtful thoughtful thoughtful thoughtful comments comments comments comments comments comments comments comments comments comments comments showed that an overwhelming overwhelming overwhelming overwhelming overwhelming overwhelming overwhelming overwhelming overwhelming overwhelming overwhelming majority majority majority majority majority majority majority majority majority majority majority 

served to validate both the CAIB evaluation of NASA and the served to validate validate validate validate validate validate validate validate validate validate both the CAIB evaluation evaluation evaluation evaluation evaluation evaluation evaluation evaluation evaluation evaluation of NASA and the 

Diaz Team Matrix. With the help of the One NASA Team, the Diaz Team Matrix. Matrix. Matrix. Matrix. Matrix. Matrix. Matrix. Matrix. Matrix. Matrix. Matrix. With the help of the One NASA Team, the 

Diaz Team organized the Agency-wide feedback and the Diaz Diaz Team organized ganized ganized ganized ganized ganized ganized ganized ganized ganized the Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback and the Diaz 

Team Matrix itself into distinct categories, which is discussed Team Matrix itself into distinct distinct distinct distinct distinct distinct distinct distinct distinct distinct distinct categories, categories, categories, categories, categories, categories, categories, categories, categories, categories, categories, which is discussed discussed discussed discussed discussed discussed discussed discussed discussed discussed discussed 

throughout the Report.

The Team identifi ed 85 R-O-Fs that it determined to have The Team identified 85 R-O-Fs that it determined to have

Agency-wide applicability. (See Figure 2.) The Team developed Agency-wide applicability. (See Figure 2.) The Team developed

40 “Specifi c Actions” for NASA to take in order to meet the 40 “Specific Actions” for NASA to take in order to meet the

requirements contained in those R-O-Fs. Each action consists of requirements contained in those R-O-Fs. Each action consists of

multiple tasks and requires a detailed implementation plan. Each multiple tasks and requires a detailed implementation plan. Each

action has been assigned a NASA Headquarters code, signifying action has been assigned a NASA Headquarters code, signifying

which organization has primary responsibility for implementing which organization has primary responsibility for implementing

that action. Figure 3 shows the distribution of the actions across that action. Figure 3 shows the distribution of the actions across

seven Headquarters organizations. seven Headquarters organizations.

In addition, the Team has identifi ed a limited number of “Diaz In addition, the Team has identified a limited number of “Diaz

Team Goals.” Given the broad nature of these goals, the Diaz Team Goals.” Given the broad nature of these goals, the Diaz

Team has not made a specifi c suggestion with respect to as- Team has not made a specific suggestion with respect to assigning responsibility for their implementation. However, it is signing responsibility for their implementation. However, it is

expected that the Agency would respond to these goals in sub- expected that the Agency would respond to these goals in subsequent planning. sequent planning.

Beyond these 85 R-O-Fs, it was recognized that while the re- Beyond these 85 R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, it was recognized recognized recognized recognized recognized recognized recognized recognized recognized recognized that while the remaining elements might not have Agency-wide applicability, maining maining maining maining maining maining maining maining maining maining maining elements elements elements elements elements elements elements elements elements elements elements might not have Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability, 

they might have applicability outside the Human Space Flight they might have applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability outside outside outside outside outside outside outside outside outside outside the Human Space Flight 

Program and therefore should not be overlooked. Individual or- Program Program Program Program Program Program Program Program Program Program Program and therefore therefore therefore therefore therefore therefore therefore therefore therefore therefore therefore should not be overlooked. overlooked. overlooked. overlooked. overlooked. overlooked. overlooked. overlooked. overlooked. overlooked. overlooked. Individual Individual Individual Individual Individual Individual Individual Individual Individual Individual Individual organizations may very well fi nd that some have bearing on their ganizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations may very well find that some have bearing bearing bearing bearing bearing bearing bearing bearing bearing bearing on their 

projects. This will be especially true for programs that conduct projects. projects. projects. projects. projects. projects. projects. projects. projects. projects. projects. This will be especially especially especially especially especially especially especially especially especially especially especially true for programs programs programs programs programs programs programs programs programs programs programs that conduct conduct conduct conduct conduct conduct conduct conduct conduct conduct conduct 

aircraft operations or support development of new aerospace aircraft aircraft aircraft aircraft aircraft aircraft aircraft aircraft aircraft aircraft operations operations operations operations operations operations operations operations operations operations or support support support support support support support support support support development development development development development development development development development development of new aerospace aerospace aerospace aerospace aerospace aerospace aerospace aerospace aerospace aerospace 

Figure 1. The Diaz Team process required wide acceptance and dissemination of all determinations.

Multiple Iterations

& Reviews with Diaz Team,

HQ Codes, & Center Directors

Release Draft

Diaz Team Matrix

For Review

Assemble Team

&

Define Requirements

Analysis To

Identify Broadly

Applicable R-O-Fs

Compile &

Evaluate 

Safety & Mission

Success Week

Feedback

Release Draft for

Safety & Mission

Success Week

Release Diaz

Team Report

January 2004

Develop Actions

& Assign

Responsibilities

Release Diaz Team 

Report Draft for Review
7

Figure 2. Diaz Team determination of broadly applicable R-O-Fs for the Agency.

Figure 3. Seven NASA organizations have actions resulting from the Diaz determinations.
8

vehicles such as the Next-Generation Vehicle or next-generation vehicles vehicles vehicles vehicles vehicles vehicles vehicles vehicles vehicles vehicles vehicles vehicles such as the Next-Generation Next-Generation Next-Generation Next-Generation Next-Generation Next-Generation Next-Generation Next-Generation Next-Generation Next-Generation Next-Generation Next-Generation Vehicle or next-generation next-generation next-generation next-generation next-generation next-generation next-generation next-generation next-generation next-generation next-generation next-generation 

launch technologies. The Team encourages these organizations launch technologies. technologies. technologies. technologies. technologies. technologies. technologies. technologies. technologies. technologies. technologies. The Team encourages encourages encourages encourages encourages encourages encourages encourages encourages encourages encourages these organizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations 

to address the additional R-O-Fs in the same way that the Diaz to address address address address address address address address address address address the additional additional additional additional additional additional additional additional additional additional additional R-O-Fs in the same way that the Diaz 

Team, Return to Flight (RTF) Team, and Continuing Flight Team Team, Return to Flight (RTF) Team, and Continuing Continuing Continuing Continuing Continuing Continuing Continuing Continuing Continuing Continuing Continuing Continuing Flight Team 

(CFT) have done. These teams have each developed implemen- (CFT) have done. These teams have each developed developed developed developed developed developed developed developed developed developed developed implemen- implemen- implemen- implemen- implemen- implemen- implemen- implemen- implemen- implemen- implementation plans to address the CAIB R-O-Fs. Since these plans have tation plans to address address address address address address address address address address address address the CAIB R-O-Fs. R-O-Fs. R-O-Fs. R-O-Fs. R-O-Fs. R-O-Fs. R-O-Fs. R-O-Fs. R-O-Fs. R-O-Fs. R-O-Fs. R-O-Fs. Since these plans have 

overlapping actions that address each R-O-F, it will be important overlapping overlapping overlapping overlapping overlapping overlapping overlapping overlapping overlapping overlapping overlapping actions actions actions actions actions actions actions actions actions actions actions that address address address address address address address address address address address each R-O-F, it will be important important important important important important important important important important important 

for NASA Headquarters to coordinate these activities. Figure 4 for NASA Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters to coordinate coordinate coordinate coordinate coordinate coordinate coordinate coordinate coordinate coordinate coordinate coordinate these activities. activities. activities. activities. activities. activities. activities. activities. activities. activities. activities. activities. Figure 4 

shows how these plans relate to each other. Specifi c expectations shows how these plans relate to each other. Specifi Specic expectations expectations expectations expectations expectations expectations expectations expectations expectations expectations expectations 

with respect to the development of the Renewed Commitment with respect respect respect respect respect respect respect respect respect respect respect respect to the development development development development development development development development development development development development of the Renewed Renewed Renewed Renewed Renewed Renewed Renewed Renewed Renewed Renewed Renewed Renewed Commitment Commitment Commitment Commitment Commitment Commitment Commitment Commitment Commitment Commitment Commitment Commitment 

to Excellence Implementation Plan(s) are discussed in “Next to Excellence Excellence Excellence Excellence Excellence Excellence Excellence Excellence Excellence Excellence Excellence Implementation Implementation Implementation Implementation Implementation Implementation Implementation Implementation Implementation Implementation Implementation Plan(s) Plan(s) Plan(s) Plan(s) Plan(s) Plan(s) Plan(s) Plan(s) Plan(s) Plan(s) Plan(s) are discussed discussed discussed discussed discussed discussed discussed discussed discussed discussed discussed in “Next 

Steps,” Section 1.9.

The Safety and Mission Success Week provided the Diaz Team The Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Success Success Success Success Success Success Success Success Success Success Success Week provided provided provided provided provided provided provided provided provided provided provided the Diaz Team 

with a valuable opportunity to engage the NASA workforce in with a valuable valuable valuable valuable valuable valuable valuable valuable valuable valuable valuable valuable opportunity opportunity opportunity opportunity opportunity opportunity opportunity opportunity opportunity opportunity opportunity opportunity to engage the NASA workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce in 

its deliberations. The free exchange of views about problems and its deliberations. deliberations. deliberations. deliberations. deliberations. deliberations. deliberations. deliberations. deliberations. deliberations. deliberations. The free exchange exchange exchange exchange exchange exchange exchange exchange exchange exchange exchange of views about problems problems problems problems problems problems problems problems problems problems problems and 

proposed solutions validated the thesis that the CAIB Report had proposed proposed proposed proposed proposed proposed proposed proposed proposed proposed proposed proposed solutions solutions solutions solutions solutions solutions solutions solutions solutions solutions solutions solutions validated validated validated validated validated validated validated validated validated validated validated validated the thesis that the CAIB Report had 

broad applicability across NASA and specifi cally the Teamʼs ap- broad applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability across NASA and specifi specically the Teamʼs approach for addressing the R-O-Fs. The Diaz Team Report uses proach for addressing addressing addressing addressing addressing addressing addressing addressing addressing addressing addressing the R-O-Fs. R-O-Fs. R-O-Fs. R-O-Fs. R-O-Fs. R-O-Fs. R-O-Fs. R-O-Fs. R-O-Fs. R-O-Fs. R-O-Fs. The Diaz Team Report uses 

statements that are derived from Safety and Mission Success statements statements statements statements statements statements statements statements statements statements statements that are derived derived derived derived derived derived derived derived derived derived derived from Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Success Success Success Success Success Success Success Success Success Success Success 

Week feedback to confi rm the Teamʼs assessments of the R-O- Week feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback to confirm the Teamʼs assessments assessments assessments assessments assessments assessments assessments assessments assessments assessments assessments of the R-OFs, and the corresponding recommended actions. 

Rather than maintain all 85 R-O-Fs as a single large group, the Rather than maintain maintain maintain maintain maintain maintain maintain maintain maintain maintain maintain all 85 R-O-Fs as a single large group, the 

Diaz Team found arranging and presenting them in categories Diaz Team found arranging arranging arranging arranging arranging arranging arranging arranging arranging arranging and presenting presenting presenting presenting presenting presenting presenting presenting presenting presenting them in categories categories categories categories categories categories categories categories categories categories 

could utilize them most effectively. After extensive analysis of could utilize utilize utilize utilize utilize utilize utilize utilize utilize utilize them most effectively fectively fectively fectively fectively fectively fectively fectively fectively fectively. After extensive extensive extensive extensive extensive extensive extensive extensive extensive extensive analysis analysis analysis analysis analysis analysis analysis analysis analysis analysis of 

the NASA workforce inputs from Safety and Mission Success the NASA workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce inputs from Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Success Success Success Success Success Success Success Success Success Success Success 

Week, the comments received were grouped into seven catego- Week, the comments comments comments comments comments comments comments comments comments comments received received received received received received received received received received were grouped grouped grouped grouped grouped grouped grouped grouped grouped grouped into seven catego- catego- catego- catego- catego- catego- catego- catego- catego- categories:

• Leadership

• Learning

• Communication

• Processes & Rules

• Technical Capabilities Technical Capabilities

• Organizational Structure Organizational Structure

• Risk Management

Each category is described in more detail throughout the Report, Each category category category category category category category category category category is described described described described described described described described described described in more detail throughout throughout throughout throughout throughout throughout throughout throughout throughout throughout the Report, Report, Report, Report, Report, Report, Report, Report, Report, Report, 

including the Diaz Teamʼs conclusions about the R-O-Fs in that including including including including including including including including including including including the Diaz Teamʼs conclusions conclusions conclusions conclusions conclusions conclusions conclusions conclusions conclusions conclusions conclusions about the R-O-Fs in that 

category. Each of the seven sections discussing the categories category category category category category category category category category category. Each of the seven sections sections sections sections sections sections sections sections sections sections discussing discussing discussing discussing discussing discussing discussing discussing discussing discussing the categories categories categories categories categories categories categories categories categories categories 

has a summary that follows the approach shown in Figure 5. 

Figure 4. Overlap currently exists between the Implementation Plans for different organizations. NASA Headquarters must coordinate 

when duplications of efforts might occur. 

Diaz

Team

Matrix

Office of Space Flight

Self Assessment

+

RTF Suggestions

Safety & Mission

Success Week

+

Continuing Dialogue

R-O-F

Broadly Applicable?

Diaz Team Report

Return

to Flight

Implementation

Plan

Continuing Flight

Implementation

Plan

NextGeneration Vehicle

Implementation

Plan(s)

Agency-Wide

Renewed Commitment

to Excellence

Implementation Plan(s)

Aircraft

Operations

Implementation

Plan(s)

Specific to Program Agency Wide

ISS

CAIB
9

Figure 5. The Diaz Team categorized the CAIB R-O-Fs into seven distinct categories, each of which has a major premise. Each 

category is fully addressed in the body of the Report.

RENEWED COMMITMENT

TO EXCELLENCE

IMPLEMENTATION PLAN(S)

RENEWED COMMITMENT

TO EXCELLENCE

IMPLEMENTATION PLAN(S)

C ts

DIAZ TEAM FINAL REPORT

Diaz Team rmination

Diaz Team Matrix

Safety & Mission Success

Week Feedback

CAIB Statement

m Determ

CAIB Statemen

P e

C ts

m rm

C ent

Premise

C

Observation

Diaz Team

Categor y

Management practices are a cause

of the accident •

•NASA has not followed its own rules

NASAhas not demonstrated the

characteristics of a learning organization •

NASA's in-house capabilities &

expertise have eroded •

•Communication did not flow effectively

NASA's safety & engineering

organizations lack authority and

independence

•

NASA fails to account for program

risk •

Leadership

Learning

Risk Management

Organizational Structure

Communications

Processes & Rules

Technical Capabilities

CAIB

WHAT DID

THE CAIB

REPORT SAY?
1 0

Table 2. The Diaz Team developed one goal for Leadership.

Leadership – Diaz Team Goal

The Agency should assess whether program management and budget formulation processes are adequate to assure there is an 

appropriate balance of requirements, resources, and risk to ensure safety and mission success.

CAIB Report Chapter 8, p203:

Leaders create culture. It is their responsibility to change it. Top administrators must take responsibility for risk, 

failure, and safety by remaining alert to the effects their decisions have on the system. Leaders are responsible 

for establishing the conditions that lead to their subordinates’ successes or failures.

1.2 LEADERSHIP

Management practices are a cause of the accident.

Agency-wide Themes

• Leaders must lead by example, creating conditions 

and a culture for safety and mission success.

• Leaders must balance schedule and risk.

• Leaders should allow and encourage diversity of 

views, eliminate retribution towards those with 

differing opinions, and understand that ”No” is an 

acceptable answer.

• Leaders should be grown throughout all levels of 

the organization, through succession planning and 

developmental experiences.

NASA has a strong heritage for developing leaders at all levels NASA has a strong heritage heritage heritage heritage heritage heritage heritage heritage heritage heritage heritage for developing developing developing developing developing developing developing developing developing developing developing leaders leaders leaders leaders leaders leaders leaders leaders leaders leaders leaders at all levels 

of the Agency who have a “can-do” attitude. They have brought of the Agency who have a “can-do” “can-do” “can-do” “can-do” “can-do” “can-do” “can-do” “can-do” “can-do” “can-do” “can-do” attitude. attitude. attitude. attitude. attitude. attitude. attitude. attitude. attitude. attitude. attitude. They have brought brought brought brought brought brought brought brought brought brought brought 

our Nation to the Moon and back, launched and managed hun- our Nation to the Moon and back, launched launched launched launched launched launched launched launched launched launched launched and managed managed managed managed managed managed managed managed managed managed managed hundreds of safe and successful human and unmanned missions to dreds of safe and successful successful successful successful successful successful successful successful successful successful successful human and unmanned unmanned unmanned unmanned unmanned unmanned unmanned unmanned unmanned unmanned unmanned missions missions missions missions missions missions missions missions missions missions missions to 

space, led us through seemingly hopeless situations like Apollo space, led us through through through through through through through through through through through through seemingly seemingly seemingly seemingly seemingly seemingly seemingly seemingly seemingly seemingly seemingly seemingly hopeless hopeless hopeless hopeless hopeless hopeless hopeless hopeless hopeless hopeless hopeless hopeless situations situations situations situations situations situations situations situations situations situations situations situations like Apollo 

13, and begun the complex construction and operation of the In- 13, and begun the complex complex complex complex complex complex complex complex complex complex complex construction construction construction construction construction construction construction construction construction construction construction and operation operation operation operation operation operation operation operation operation operation operation of the International Space Station. However, with the seriousness of the ternational ternational ternational ternational ternational ternational ternational ternational ternational ternational ternational ternational Space Station. Station. Station. Station. Station. Station. Station. Station. Station. Station. Station. Station. However However However However However However However However However However However However, with the seriousness seriousness seriousness seriousness seriousness seriousness seriousness seriousness seriousness seriousness seriousness seriousness of the 

Columbia accident and the CAIB Report, NASA leaders need to accident accident accident accident accident accident accident accident accident and the CAIB Report, Report, Report, Report, Report, Report, Report, Report, Report, NASA leaders leaders leaders leaders leaders leaders leaders leaders leaders need to 

refl ect upon and grow from the lessons learned. reflect upon and grow from the lessons learned. 

The CAIB Report had this to say about NASAʼs Leadership: The CAIB Report had this to say about NASAʼs Leadership:

Post-Challenger Challenger Challenger policy decisions made by the White policy decisions decisions decisions decisions decisions decisions decisions decisions made by the White 

House, Congress, and NASA leadership resulted in the House, Congress, Congress, Congress, Congress, Congress, Congress, Congress, Congress, Congress, Congress, and NASA leadership leadership leadership leadership leadership leadership leadership leadership leadership leadership resulted resulted resulted resulted resulted resulted resulted resulted resulted resulted in the 

Agency reproducing many of the failings identifi ed by Agency reproducing reproducing reproducing reproducing reproducing reproducing reproducing reproducing reproducing many of the failings failings failings failings failings failings failings failings failings identifi identifi identifi identifi identifi identifi identifi identifi identified by 

the Rogers Commission. Policy constraints affected the the Rogers Commission. Commission. Commission. Commission. Commission. Commission. Commission. Commission. Commission. Commission. Policy constraints constraints constraints constraints constraints constraints constraints constraints constraints constraints affected the 

Shuttle Program’s organization culture, its structure, and Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Program’ Program’ Program’ Program’ Program’ Program’ Program’ Program’ Program’s organization organization organization organization organization organization organization organization organization culture, culture, culture, culture, culture, culture, culture, culture, culture, its structure, structure, structure, structure, structure, structure, structure, structure, structure, and 

the structure of the safety system. The three combined to the structure structure structure structure structure structure structure structure structure structure of the safety system. system. system. system. system. system. system. system. system. system. The three combined combined combined combined combined combined combined combined combined combined to 

keep NASA on its slippery slope toward keep NASA on its slippery slippery slippery slippery slippery slippery slope toward Challenger and 

Columbia. (CAIB Report, Chapter 8, p. 197)

The Diaz Teamʼs actions contained in the Diaz Team Matrix The Diaz Teamʼs actions actions actions actions actions actions actions actions actions actions actions contained contained contained contained contained contained contained contained contained contained contained in the Diaz Team Matrix 

require that everyone understand their responsibilities and are require require require require require require require require require require require require that everyone everyone everyone everyone everyone everyone everyone everyone everyone everyone everyone everyone understand understand understand understand understand understand understand understand understand understand understand understand their responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities and are 

given the authority to perform their jobs, with the accountabil- given the authority authority authority authority authority authority authority authority authority authority authority to perform perform perform perform perform perform perform perform perform perform perform their jobs, with the accountabil- accountabil- accountabil- accountabil- accountabil- accountabil- accountabil- accountabil- accountabil- accountabil- accountability for their individual and programʼs successes and failures, ity for their individual individual individual individual individual individual individual individual individual individual individual individual and programʼ programʼ programʼ programʼ programʼ programʼ programʼ programʼ programʼ programʼ programʼ programʼs successes successes successes successes successes successes successes successes successes successes successes successes and failures, failures, failures, failures, failures, failures, failures, failures, failures, failures, failures, failures, 

including lessons learned. Leadership means making informed including including including including including including including including including including including lessons lessons lessons lessons lessons lessons lessons lessons lessons lessons lessons learned. learned. learned. learned. learned. learned. learned. learned. learned. learned. learned. Leadership Leadership Leadership Leadership Leadership Leadership Leadership Leadership Leadership Leadership Leadership means making informed informed informed informed informed informed informed informed informed informed informed 

decisions and treating staff and contractor support with respect decisions decisions decisions decisions decisions decisions decisions decisions decisions decisions decisions and treating treating treating treating treating treating treating treating treating treating treating staff and contractor contractor contractor contractor contractor contractor contractor contractor contractor contractor contractor support support support support support support support support support support support with respect respect respect respect respect respect respect respect respect respect respect 

and courtesy to ensure that everyone understands their inputs are and courtesy courtesy courtesy courtesy courtesy courtesy courtesy courtesy courtesy courtesy courtesy to ensure that everyone everyone everyone everyone everyone everyone everyone everyone everyone everyone everyone understands understands understands understands understands understands understands understands understands understands understands their inputs are 

valued and important. It also involves empowering and develop- valued and important. important. important. important. important. important. important. important. important. important. important. It also involves involves involves involves involves involves involves involves involves involves involves empowering empowering empowering empowering empowering empowering empowering empowering empowering empowering empowering and develop- develop- develop- develop- develop- develop- develop- develop- develop- develop- developing the workforce, listening and communicating with them more ing the workforce, workforce, workforce, workforce, workforce, workforce, workforce, workforce, workforce, workforce, workforce, workforce, listening listening listening listening listening listening listening listening listening listening listening listening and communicating communicating communicating communicating communicating communicating communicating communicating communicating communicating communicating communicating with them more 

effectively, and developing future leaders through progressive effectively fectively fectively fectively fectively fectively fectively fectively fectively fectively fectively, and developing developing developing developing developing developing developing developing developing developing developing future leaders leaders leaders leaders leaders leaders leaders leaders leaders leaders leaders through through through through through through through through through through through progressive progressive progressive progressive progressive progressive progressive progressive progressive progressive progressive 

leadership development and effective organization succession leadership leadership leadership leadership leadership leadership leadership leadership leadership leadership leadership leadership development development development development development development development development development development development development and effective fective fective fective fective fective fective fective fective fective fective fective organization ganization ganization ganization ganization ganization ganization ganization ganization ganization ganization ganization succession succession succession succession succession succession succession succession succession succession succession succession 

planning and practices. Leadership means creating a climate and planning planning planning planning planning planning planning planning planning planning and practices. practices. practices. practices. practices. practices. practices. practices. practices. practices. Leadership Leadership Leadership Leadership Leadership Leadership Leadership Leadership Leadership Leadership means creating creating creating creating creating creating creating creating creating creating a climate climate climate climate climate climate climate climate climate climate and 

conditions for NASA employees and organizations to achieve conditions conditions conditions conditions conditions conditions conditions conditions conditions conditions conditions for NASA employees employees employees employees employees employees employees employees employees employees employees and organizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations to achieve achieve achieve achieve achieve achieve achieve achieve achieve achieve achieve 

safety and mission success.

The criteria used to delineate those R-O-Fs that were applied to The criteria criteria criteria criteria criteria criteria criteria criteria criteria criteria used to delineate delineate delineate delineate delineate delineate delineate delineate delineate delineate those R-O-Fs that were applied applied applied applied applied applied applied applied applied applied to 

leadership included the Agency-wide themes and a leaderʼs abil- leadership leadership leadership leadership leadership leadership leadership leadership leadership leadership leadership included included included included included included included included included included included the Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide themes and a leaderʼs ability to make and support decisions. These criteria address: ity to make and support decisions. These criteria address:

• Empowerment by understanding and communicating 

responsibility, accountability, and authority. responsibility, accountability, and authority.

• Serving as an example and role model to employees 

by understanding and following the rules (but not 

“blindly”), and having a willingness to challenge the 

rules when safety and mission success are at stake.

• A willingness and ability to challenge schedules when A willingness and ability to challenge schedules when 

appropriate and necessary based upon well thought-out 

and presented analyses of risks.

• Respect of others and fostering fair consideration of all 

points of view. points of view.

The feedback from Safety and Mission Success Week reinforced The feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback from Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Success Success Success Success Success Success Success Success Success Success Week reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced 

the Diaz Team assessments. the Diaz Team assessments.

» We need to make sure every voice is heard without We need to make sure every voice is heard without 

fear of retaliation or suppression.

» NASA leadership has become preoccupied by actions NASA leadership has become preoccupied by actions 

to address symptoms; we need the resources and leadership commitment to fi x underlying causes. ership commitment to fix underlying causes.

» We need to stress among NASA leadership the impor- We need to stress among NASA leadership the importance of responding to even the lowest level question. 

This was exactly why NASA did not exercise addition- This was exactly why NASA did not exercise additional techniques with Columbia to research the problem.

Every member of the workforce must know his or her position Every member of the workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce must know his or her position position position position position position position position position position 

in the organization; all must know their authority, responsibility, in the organization; ganization; ganization; ganization; ganization; ganization; ganization; ganization; ganization; ganization; all must know their authority authority authority authority authority authority authority authority authority authority, responsibility responsibility responsibility responsibility responsibility responsibility responsibility responsibility responsibility responsibility, 

and accountability. The Diaz Team came to believe that at the and accountability accountability accountability accountability accountability accountability accountability accountability accountability accountability accountability. The Diaz Team came to believe believe believe believe believe believe believe believe believe believe believe that at the 

root of some of the CAIB observations and individual comments root of some of the CAIB observations observations observations observations observations observations observations observations observations observations and individual individual individual individual individual individual individual individual individual individual comments comments comments comments comments comments comments comments comments comments 

was a concern about leadershipʼs ability to determine whether was a concern concern concern concern concern concern concern concern concern concern concern about leadershipʼ leadershipʼ leadershipʼ leadershipʼ leadershipʼ leadershipʼ leadershipʼ leadershipʼ leadershipʼ leadershipʼ leadershipʼs ability ability ability ability ability ability ability ability ability ability ability to determine determine determine determine determine determine determine determine determine determine determine whether whether whether whether whether whether whether whether whether whether whether 

there was an appropriate balance between requirements and there was an appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate balance balance balance balance balance balance balance balance balance balance between between between between between between between between between between requirements requirements requirements requirements requirements requirements requirements requirements requirements requirements and 

resources allocated to their achievement. The Diaz Team goal resources resources resources resources resources resources resources resources resources resources resources allocated allocated allocated allocated allocated allocated allocated allocated allocated allocated allocated to their achievement. achievement. achievement. achievement. achievement. achievement. achievement. achievement. achievement. achievement. achievement. The Diaz Team goal 

on Leadership was developed in response to that concern. For on Leadership Leadership Leadership Leadership Leadership Leadership Leadership Leadership Leadership Leadership was developed developed developed developed developed developed developed developed developed developed in response response response response response response response response response response to that concern. concern. concern. concern. concern. concern. concern. concern. concern. concern. For 

this goal to succeed, changes discussed in other sections of the this goal to succeed, succeed, succeed, succeed, succeed, succeed, succeed, succeed, succeed, succeed, changes changes changes changes changes changes changes changes changes changes discussed discussed discussed discussed discussed discussed discussed discussed discussed discussed in other sections sections sections sections sections sections sections sections sections sections of the 

Report must also be pursued.

In addition to the actions in the Diaz Team Matrix that address In addition addition addition addition addition addition addition addition addition addition addition to the actions actions actions actions actions actions actions actions actions actions actions in the Diaz Team Matrix that address address address address address address address address address address address 

each R-O-F, the Diaz Team has one goal addressing the Leader- each R-O-F, the Diaz Team has one goal addressing addressing addressing addressing addressing addressing addressing addressing addressing addressing the Leadership category, as shown in Table 2. ship category, as shown in Table 2.
1 1

1.3 LEARNING

CAIB Report Chapter 7, p192:

The Board concludes that NASA’s current organization does not provide effective checks-and-balances, does not 

have an independent safety program, and has not demonstrated the characteristics of a learning organization. 

NASA has not demonstrated the characteristics 

of a learning organization.

Agency-wide Themes

• NASA should provide robust simulation and emergency response training.

• Tools, databases, and models should be developed 

and used appropriately.

Much was said in the CAIB Report about the NASA culture and Much was said in the CAIB Report about the NASA culture culture culture culture culture culture culture culture culture culture culture culture and 

how its attributes contributed to the how its attributes attributes attributes attributes attributes attributes contributed contributed contributed contributed contributed contributed to the Columbia accident. The accident. The 

CAIB concluded NASA “has not demonstrated the characteris- CAIB concluded concluded concluded concluded concluded concluded concluded concluded concluded concluded concluded concluded NASA “has not demonstrated demonstrated demonstrated demonstrated demonstrated demonstrated demonstrated demonstrated demonstrated demonstrated demonstrated demonstrated the characteris- characteris- characteris- characteris- characteris- characteris- characteris- characteris- characteris- characteris- characteris- characteristics of a learning organization” after investigators observed mis- tics of a learning learning learning learning learning learning learning learning learning learning learning organization” ganization” ganization” ganization” ganization” ganization” ganization” ganization” ganization” ganization” ganization” after investigators investigators investigators investigators investigators investigators investigators investigators investigators investigators investigators observed observed observed observed observed observed observed observed observed observed observed mistakes being repeated and lessons from the past apparently being takes being repeated repeated repeated repeated repeated repeated repeated repeated repeated repeated repeated repeated and lessons lessons lessons lessons lessons lessons lessons lessons lessons lessons lessons lessons from the past apparently apparently apparently apparently apparently apparently apparently apparently apparently apparently apparently apparently being 

relearned. The CAIB provided NASA with a number of recom- relearned. relearned. relearned. relearned. relearned. relearned. relearned. relearned. relearned. relearned. relearned. The CAIB provided provided provided provided provided provided provided provided provided provided provided NASA with a number of recommendations and fi ndings that could help it achieve the benefi cial mendations mendations mendations mendations mendations mendations mendations mendations mendations mendations mendations and findings that could help it achieve achieve achieve achieve achieve achieve achieve achieve achieve achieve achieve the beneficial 

traits of a learning organization. traits of a learning organization.

It is recognized there are efforts underway in NASA to address It is recognized recognized recognized recognized recognized recognized recognized recognized recognized recognized recognized recognized there are efforts underway underway underway underway underway underway underway underway underway underway underway underway in NASA to address address address address address address address address address address address address 

knowledge capture, management, and dissemination. These ac- knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge capture, capture, capture, capture, capture, capture, capture, capture, capture, capture, capture, management, management, management, management, management, management, management, management, management, management, management, and dissemination. dissemination. dissemination. dissemination. dissemination. dissemination. dissemination. dissemination. dissemination. dissemination. dissemination. These actions are in response to the concern for the impending retirement tions are in response response response response response response response response response response response response to the concern concern concern concern concern concern concern concern concern concern concern concern for the impending impending impending impending impending impending impending impending impending impending impending impending retirement retirement retirement retirement retirement retirement retirement retirement retirement retirement retirement retirement 

of a large segment of the NASA workforce. But more needs to of a large segment segment segment segment segment segment segment segment segment segment segment of the NASA workforce. workforce. workforce. workforce. workforce. workforce. workforce. workforce. workforce. workforce. workforce. But more needs to 

be done to understand what the knowledge architecture in NASA be done to understand understand understand understand understand understand understand understand understand understand understand understand what the knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge architecture architecture architecture architecture architecture architecture architecture architecture architecture architecture architecture architecture in NASA

is so that steps can be taken to preserve it. NASA needs a robust is so that steps can be taken to preserve preserve preserve preserve preserve preserve preserve preserve preserve preserve preserve it. NASA needs a robust 

infrastructure to support all aspects of decision-making and infrastructure infrastructure infrastructure infrastructure infrastructure infrastructure infrastructure infrastructure infrastructure infrastructure infrastructure to support support support support support support support support support support support all aspects aspects aspects aspects aspects aspects aspects aspects aspects aspects aspects of decision-making decision-making decision-making decision-making decision-making decision-making decision-making decision-making decision-making decision-making decision-making and 

knowledge management. The CAIB Report said that NASA has knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge management. management. management. management. management. management. management. management. management. management. management. management. The CAIB Report said that NASA has 

“dysfunctional databases.” Since NASA has a geographically “dysfunctional “dysfunctional “dysfunctional “dysfunctional “dysfunctional “dysfunctional “dysfunctional “dysfunctional “dysfunctional “dysfunctional “dysfunctional databases.” databases.” databases.” databases.” databases.” databases.” databases.” databases.” databases.” databases.” databases.” Since NASA has a geographically geographically geographically geographically geographically geographically geographically geographically geographically geographically geographically 

dispersed organization consisting of a relatively small Headquar- dispersed dispersed dispersed dispersed dispersed dispersed dispersed dispersed dispersed dispersed dispersed dispersed organization ganization ganization ganization ganization ganization ganization ganization ganization ganization ganization ganization consisting consisting consisting consisting consisting consisting consisting consisting consisting consisting consisting consisting of a relatively relatively relatively relatively relatively relatively relatively relatively relatively relatively relatively relatively small Headquar Headquar Headquar Headquar Headquar Headquar Headquar Headquar Headquar Headquar Headquar Headquarters with many Center facilities around the country, a suitable ters with many Center facilities facilities facilities facilities facilities facilities facilities facilities facilities facilities facilities around the country country country country country country country country country country country, a suitable suitable suitable suitable suitable suitable suitable suitable suitable suitable suitable 

information storage and transfer system is essential to facilitate information information information information information information information information information information information information storage storage storage storage storage storage storage storage storage storage storage storage and transfer transfer transfer transfer transfer transfer transfer transfer transfer transfer transfer transfer system is essential essential essential essential essential essential essential essential essential essential essential essential to facilitate facilitate facilitate facilitate facilitate facilitate facilitate facilitate facilitate facilitate facilitate facilitate 

communication and learning. The CAIB had this to say: communication and learning. The CAIB had this to say:

In its investigation, the Board found that the information In its investigation, investigation, investigation, investigation, investigation, investigation, investigation, investigation, investigation, the Board found that the information information information information information information information information information 

systems that support the Shuttle Program are extremely systems systems systems systems systems systems systems systems systems that support support support support support support support support support the Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Program Program Program Program Program Program Program Program Program are extremely extremely extremely extremely extremely extremely extremely extremely extremely 

cumbersome and diffi cult to use in decision-making at cumbersome cumbersome cumbersome cumbersome cumbersome cumbersome cumbersome cumbersome cumbersome cumbersome and difficult to use in decision-making decision-making decision-making decision-making decision-making decision-making decision-making decision-making decision-making decision-making at 

any level. For obvious reasons, these shortcomings any level. For obvious obvious obvious obvious obvious obvious obvious obvious obvious reasons, reasons, reasons, reasons, reasons, reasons, reasons, reasons, reasons, these shortcomings shortcomings shortcomings shortcomings shortcomings shortcomings shortcomings shortcomings shortcomings 

imperil the Shuttle Program’s ability to disseminate and imperil imperil imperil imperil imperil imperil imperil imperil imperil imperil the Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Program’ Program’ Program’ Program’ Program’ Program’ Program’ Program’ Program’ Program’s ability ability ability ability ability ability ability ability ability ability to disseminate disseminate disseminate disseminate disseminate disseminate disseminate disseminate disseminate disseminate and 

share critical information among its many layers. (CAIB share critical critical critical critical critical critical critical critical critical information information information information information information information information information among its many layers. layers. layers. layers. layers. layers. layers. layers. layers. (CAIB 

Report, Chapter 7, p. 189)

NASA personnel need to achieve a high level of technical and NASA personnel personnel personnel personnel personnel personnel personnel personnel personnel personnel personnel need to achieve achieve achieve achieve achieve achieve achieve achieve achieve achieve achieve a high level of technical technical technical technical technical technical technical technical technical technical technical and 

managerial competency along with a high state of readiness to managerial managerial managerial managerial managerial managerial managerial managerial managerial managerial managerial competency competency competency competency competency competency competency competency competency competency competency along with a high state of readiness readiness readiness readiness readiness readiness readiness readiness readiness readiness readiness to 

deal with the research, developmental, and operational challeng- deal with the research, research, research, research, research, research, research, research, research, research, research, developmental, developmental, developmental, developmental, developmental, developmental, developmental, developmental, developmental, developmental, developmental, and operational operational operational operational operational operational operational operational operational operational operational challeng- challeng- challeng- challeng- challeng- challeng- challeng- challeng- challeng- challeng- challenges inherent in the aerospace systems they manage and operate. In es inherent inherent inherent inherent inherent inherent inherent inherent inherent inherent inherent inherent in the aerospace aerospace aerospace aerospace aerospace aerospace aerospace aerospace aerospace aerospace aerospace aerospace systems systems systems systems systems systems systems systems systems systems systems systems they manage and operate. operate. operate. operate. operate. operate. operate. operate. operate. operate. operate. operate. In 

concert, the technical tools, information systems, and knowledge concert, concert, concert, concert, concert, concert, concert, concert, concert, concert, concert, the technical technical technical technical technical technical technical technical technical technical technical tools, information information information information information information information information information information information systems, systems, systems, systems, systems, systems, systems, systems, systems, systems, systems, and knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge 

repositories of the Agency must be up to date and readily avail- repositories repositories repositories repositories repositories repositories repositories repositories repositories repositories repositories repositories of the Agency must be up to date and readily readily readily readily readily readily readily readily readily readily readily readily available to be used by personnel across the Agency. NASA can ex- able to be used by personnel personnel personnel personnel personnel personnel personnel personnel personnel personnel personnel across the Agency. NASA can explore personnel training and learning through a variety of meth- plore personnel personnel personnel personnel personnel personnel personnel personnel personnel personnel personnel personnel training training training training training training training training training training training training and learning learning learning learning learning learning learning learning learning learning learning learning through through through through through through through through through through through through a variety variety variety variety variety variety variety variety variety variety variety variety of methods. More on-the-job training through apprenticeship programs ods. More on-the-job on-the-job on-the-job on-the-job on-the-job on-the-job on-the-job on-the-job on-the-job on-the-job on-the-job training training training training training training training training training training training through through through through through through through through through through through apprenticeship apprenticeship apprenticeship apprenticeship apprenticeship apprenticeship apprenticeship apprenticeship apprenticeship apprenticeship apprenticeship programs programs programs programs programs programs programs programs programs programs programs 

and hands-on work can be emphasized for critical skills being and hands-on hands-on hands-on hands-on hands-on hands-on hands-on hands-on hands-on hands-on hands-on hands-on work can be emphasized emphasized emphasized emphasized emphasized emphasized emphasized emphasized emphasized emphasized emphasized emphasized for critical critical critical critical critical critical critical critical critical critical critical critical skills being 

lost at the Centers. In addition, comprehensive and systematic lost at the Centers. Centers. Centers. Centers. Centers. Centers. Centers. Centers. Centers. Centers. Centers. In addition, addition, addition, addition, addition, addition, addition, addition, addition, addition, addition, comprehensive comprehensive comprehensive comprehensive comprehensive comprehensive comprehensive comprehensive comprehensive comprehensive comprehensive and systematic systematic systematic systematic systematic systematic systematic systematic systematic systematic systematic 

emergency response training simulating the work environment, emergency response response response response response response response response response response response response training training training training training training training training training training training training simulating simulating simulating simulating simulating simulating simulating simulating simulating simulating simulating simulating the work environment, environment, environment, environment, environment, environment, environment, environment, environment, environment, environment, environment, 

as well as hands-on experience, are critical to creating a learning as well as hands-on hands-on hands-on hands-on hands-on hands-on hands-on hands-on hands-on hands-on hands-on experience, experience, experience, experience, experience, experience, experience, experience, experience, experience, experience, are critical critical critical critical critical critical critical critical critical critical critical to creating creating creating creating creating creating creating creating creating creating creating a learning learning learning learning learning learning learning learning learning learning learning 

organization. organization. 

The feedback from Safety and Mission Success Week reinforced The feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback from Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Success Success Success Success Success Success Success Success Success Success Success Week reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced 

the Diaz Team assessment: the Diaz Team assessment:

» Mandate that current and new employees moving into Mandate that current and new employees moving into

management positions attend a lecture (sponsored by management positions attend a lecture (sponsored by

NASA) outlining historical lessons learned by NASA NASA) outlining historical lessons learned by NASA

and comparable agencies. This lecture should be at and comparable agencies. This lecture should be at

least one day long and should cover lessons learned in least one day long and should cover lessons learned in

several disasters ( several disasters (Challenger Challenger,Columbia Columbia, Apollo 1 Apollo 1, USS

Thresher Thresher) and close calls (i.e. STS-93 and ) and close calls (i.e. STS-93 and Apollo 13 Apollo 13).

» NASA should routinely run mock mishap investiga- NASA should routinely run mock mishap investigations to root out its process, product, and programmatic tions to root out its process, process, process, process, process, process, process, process, process, product, product, product, product, product, product, product, product, product, and programmatic programmatic programmatic programmatic programmatic programmatic programmatic programmatic programmatic 

weaknesses before a mishap actually happens.

» NASA does not effectively transfer knowledge. NASA NASA does not effectively transfer knowledge. NASA

can signifi cantly improve our knowledge management can significantly improve our knowledge management 

culture with lessons learned processes, trend analyses, 

transferring expert knowledge from people to systems, 

and portals that share information.

» NASA should employ a more rigorous/disciplined ac- NASA should employ a more rigorous/disciplined acceptance testing & checkout procedure prior to placing 

any system (hardware or software) in operation. The any system (hardware or software) in operation. The 

requirements and results should be kept in a database 

with an independent group auditing input.

NASA can assure being a learning organization by: NASA can assure being a learning organization by:

1. Developing and using an Agency-wide knowledge Developing and using an Agency-wide knowledge 

management system to foster sound decision-making practices. Programs must have the ability to share 

information using central databases.

2. Requiring programs to have contingency and emer- Requiring programs to have contingency and emergency response processes in place, and requiring the 

programs to conduct rigorous and ongoing training in 

those processes. 

In addition to the actions in the Diaz Team Matrix that address In addition addition addition addition addition addition addition addition addition addition addition addition to the actions actions actions actions actions actions actions actions actions actions actions actions in the Diaz Team Matrix that address address address address address address address address address address address address 

each R-O-F, the Diaz Team has one goal addressing the Learning each R-O-F, the Diaz Team has one goal addressing addressing addressing addressing addressing addressing addressing addressing addressing addressing addressing the Learning Learning Learning Learning Learning Learning Learning Learning Learning Learning Learning 

category, as shown in Table 3. category, as shown in Table 3.

Table 3. The Diaz Team developed one goal for Learning.

Learning – Diaz Team Goal

The Agency should identify an appropriate approach for the future development of a knowledge management system and 

infrastructure to assure knowledge retention and lessons learned.
1 2

CAIB Report Chapter 6, p170:

Management decisions made during Columbia’s fi nal fl ight refl ect missed opportunities, blocked or ineffective 

communication channels, fl awed analysis, and ineffective leadership. Perhaps most striking is the fact that 

management – including Shuttle Program, Mission Management Team, Mission Evaluation Room, and Flight 

Director and Mission Control – displayed no interest in understanding a problem and its implications.

1.4 COMMUNICATION

Communication did not fl ow effectively. 

Agency-wide Themes

• Anomalies should be considered problems until 

proven otherwise.

• Responsibility, authority, and accountability must 

be clearly understood and communicated.

• Communications need to fl ow both up and down 

the chain of command.

• Diverse viewpoints must be fostered and minority views considered.

• Communication practices must be validated and 

tested to ensure effective communication across 

NASA.

The CAIB Report discussed communication at all levels. The The CAIB Report discussed discussed discussed discussed discussed discussed discussed discussed discussed discussed discussed communication communication communication communication communication communication communication communication communication communication communication at all levels. levels. levels. levels. levels. levels. levels. levels. levels. levels. levels. The 

lack of effective communication from Headquarters to every lack of effective fective fective fective fective fective fective fective fective fective fective communication communication communication communication communication communication communication communication communication communication communication from Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters to every 

member of the NASA workforce is a continuing problem, and member of the NASA workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce is a continuing continuing continuing continuing continuing continuing continuing continuing continuing continuing continuing continuing problem, problem, problem, problem, problem, problem, problem, problem, problem, problem, problem, problem, and 

was stressed in the Safety and Mission Success Week feedback. was stressed stressed stressed stressed stressed stressed stressed stressed stressed stressed stressed in the Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Success Success Success Success Success Success Success Success Success Success Success Week feedback. feedback. feedback. feedback. feedback. feedback. feedback. feedback. feedback. feedback. feedback. 

This is what the CAIB had to say about communication: 

The organizational structure and hierarchy blocked effec- The organizational organizational organizational organizational organizational organizational organizational organizational organizational organizational structure structure structure structure structure structure structure structure structure structure and hierarchy hierarchy hierarchy hierarchy hierarchy hierarchy hierarchy hierarchy hierarchy hierarchy blocked blocked blocked blocked blocked blocked blocked blocked blocked blocked effective communication of technical problems. Signals were tive communication communication communication communication communication communication communication communication communication of technical technical technical technical technical technical technical technical technical problems. problems. problems. problems. problems. problems. problems. problems. problems. Signals Signals Signals Signals Signals Signals Signals Signals Signals were 

over-looked, people were silenced, and useful information over-looked, over-looked, over-looked, over-looked, over-looked, over-looked, over-looked, over-looked, over-looked, people were silenced, silenced, silenced, silenced, silenced, silenced, silenced, silenced, silenced, and useful information information information information information information information information information 

and dissenting views on technical issues did not surface and dissenting dissenting dissenting dissenting dissenting dissenting dissenting dissenting dissenting dissenting views on technical technical technical technical technical technical technical technical technical technical issues did not surface surface surface surface surface surface surface surface surface surface 

at higher levels. (CAIB Report, Chapter 8, p. 201)

When broadly applied, the Diaz Team actions for Communica- When broadly broadly broadly broadly broadly broadly broadly broadly broadly broadly broadly applied, applied, applied, applied, applied, applied, applied, applied, applied, applied, applied, the Diaz Team actions actions actions actions actions actions actions actions actions actions actions for Communica- Communica- Communica- Communica- Communica- Communica- Communica- Communica- Communica- Communica- Communication focus on developing a management and communication tion focus on developing developing developing developing developing developing developing developing developing developing developing developing a management management management management management management management management management management management management and communication communication communication communication communication communication communication communication communication communication communication communication 

culture that is based on adequate discourse for anomaly reso- culture culture culture culture culture culture culture culture culture culture culture that is based on adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate discourse discourse discourse discourse discourse discourse discourse discourse discourse discourse discourse for anomaly anomaly anomaly anomaly anomaly anomaly anomaly anomaly anomaly anomaly anomaly resolution, a clear process for chain of command and contingency lution, lution, lution, lution, lution, lution, lution, lution, lution, lution, lution, lution, a clear process process process process process process process process process process process process for chain of command command command command command command command command command command command command and contingency contingency contingency contingency contingency contingency contingency contingency contingency contingency contingency contingency 

communication, and the codifi cation of formal communication communication, communication, communication, communication, communication, communication, communication, communication, communication, communication, communication, and the codification of formal communication communication communication communication communication communication communication communication communication communication communication 

and reporting policies and procedures. This cultural change re- and reporting reporting reporting reporting reporting reporting reporting reporting reporting reporting reporting policies policies policies policies policies policies policies policies policies policies policies and procedures. procedures. procedures. procedures. procedures. procedures. procedures. procedures. procedures. procedures. procedures. This cultural cultural cultural cultural cultural cultural cultural cultural cultural cultural cultural change requires that NASA return to the process that considers anomalies quires that NASA return to the process process process process process process process process process process process process that considers considers considers considers considers considers considers considers considers considers considers considers anomalies anomalies anomalies anomalies anomalies anomalies anomalies anomalies anomalies anomalies anomalies anomalies 

as problems until proven otherwise. This philosophy, supported as problems problems problems problems problems problems problems problems problems problems problems until proven otherwise. otherwise. otherwise. otherwise. otherwise. otherwise. otherwise. otherwise. otherwise. otherwise. otherwise. This philosophy philosophy philosophy philosophy philosophy philosophy philosophy philosophy philosophy philosophy philosophy, supported supported supported supported supported supported supported supported supported supported supported 

by a clear chain of command also supports contingency com- by a clear chain of command command command command command command command command command command command command also supports supports supports supports supports supports supports supports supports supports supports supports contingency contingency contingency contingency contingency contingency contingency contingency contingency contingency contingency contingency communication, or escalation paths, so that disagreements can be munication, munication, munication, munication, munication, munication, munication, munication, munication, munication, munication, or escalation escalation escalation escalation escalation escalation escalation escalation escalation escalation escalation paths, so that disagreements disagreements disagreements disagreements disagreements disagreements disagreements disagreements disagreements disagreements disagreements can be 

addressed to enhance anomaly resolution. 

The feedback from Safety and Mission Success Week reinforced The feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback from Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Success Success Success Success Success Success Success Success Success Success Success Week reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced 

the Diaz Team assessment: the Diaz Team assessment:

» When concerns are raised, the prevailing attitude in 

NASA management is to require the concerned person NASA management is to require the concerned person 

or organization prove that something is a problem or organization prove that something is a problem 

before action will be taken. The action may be just before action will be taken. The action may be just 

more analysis and testing. If the concerned person or 

organization cannot furnish data to prove a problem organization cannot furnish data to prove a problem 

exists, no action will be taken.

» One of the barriers that should be broken down is the 

communication barrier. The NASA workforce should communication barrier. The NASA workforce should 

feel comfortable to bring forward comments. 

» Why is it not OK to ask Why? Why is it not OK to ask Why?

» There is fear of reprisal for openly communicating dissenting opinions.

» Most are reluctant to say anything for fear of criticism 

or they feel it isnʼt worth it. People have tried in the or they feel it isnʼt worth it. People have tried in the 

past to point things out but know itʼs not going to get past to point things out but know itʼs not going to get 

them anywhere. NASA culture does not encourage or them anywhere. NASA culture does not encourage or 

reward people who speak out.

» There is a lack of a formal and effective structure to There is a lack of a formal and effective structure to 

facilitate information fl ow up and down the manage- facilitate information flow up and down the management chain.

The Safety and Mission Success feedback indicated a sense from The Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Success Success Success Success Success Success Success Success Success Success Success feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback indicated indicated indicated indicated indicated indicated indicated indicated indicated indicated indicated a sense from 

some in the workforce that they have lost the ability to participate some in the workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce that they have lost the ability ability ability ability ability ability ability ability ability ability to participate participate participate participate participate participate participate participate participate participate 

in the decision-making process. The feedback also suggests that in the decision-making decision-making decision-making decision-making decision-making decision-making decision-making decision-making decision-making decision-making decision-making process. process. process. process. process. process. process. process. process. process. process. The feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback also suggests suggests suggests suggests suggests suggests suggests suggests suggests suggests suggests that 

there is a segment of the workforce with the desire to participate there is a segment segment segment segment segment segment segment segment segment segment of the workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce with the desire to participate participate participate participate participate participate participate participate participate participate 

but who are afraid to do so. They are uncertain about their roles, but who are afraid to do so. They are uncertain uncertain uncertain uncertain uncertain uncertain uncertain uncertain uncertain uncertain uncertain about their roles, 

and have a lack of understanding of the processes for dissent. and have a lack of understanding understanding understanding understanding understanding understanding understanding understanding understanding understanding of the processes processes processes processes processes processes processes processes processes processes for dissent. dissent. dissent. dissent. dissent. dissent. dissent. dissent. dissent. dissent. 

In the Diaz Teamʼs analysis of the Safety and Mission Success In the Diaz Teamʼs analysis analysis analysis analysis analysis analysis analysis analysis analysis analysis of the Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Success Success Success Success Success Success Success Success Success Success 

Week data, problematic communication was a recurring theme Week data, problematic problematic problematic problematic problematic problematic problematic problematic problematic problematic problematic communication communication communication communication communication communication communication communication communication communication communication was a recurring recurring recurring recurring recurring recurring recurring recurring recurring recurring recurring theme 

from Headquarters and every Center. Communication has a from Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters and every Center. Communication Communication Communication Communication Communication Communication Communication Communication Communication Communication has a 

chance to improve when:

1. There is no fear of retribution.

2. Information is considered in an unbiased manner. Information is considered in an unbiased manner.

3. Every opinion is treated with respect.

4. Decision feedback is provided.

The CAIB fi ndings and Diaz Team actions identify means to start The CAIB findings and Diaz Team actions actions actions actions actions actions actions actions actions actions actions identify identify identify identify identify identify identify identify identify identify identify means to start 

building a more effective communication strategy. However, building building building building building building building building building building a more effective fective fective fective fective fective fective fective fective fective communication communication communication communication communication communication communication communication communication communication strategy strategy strategy strategy strategy strategy strategy strategy strategy strategy. However However However However However However However However However However, 

change in communication requires that leaders adopt differ- change in communication communication communication communication communication communication communication communication communication communication communication requires requires requires requires requires requires requires requires requires requires requires that leaders leaders leaders leaders leaders leaders leaders leaders leaders leaders leaders adopt different behavior and communication philosophies. Leaders should ent behavior behavior behavior behavior behavior behavior behavior behavior behavior behavior and communication communication communication communication communication communication communication communication communication communication philosophies. philosophies. philosophies. philosophies. philosophies. philosophies. philosophies. philosophies. philosophies. philosophies. Leaders Leaders Leaders Leaders Leaders Leaders Leaders Leaders Leaders Leaders should 

promote a diversity of viewpoints. Fear of retribution must be promote promote promote promote promote promote promote promote promote promote promote a diversity diversity diversity diversity diversity diversity diversity diversity diversity diversity diversity of viewpoints. viewpoints. viewpoints. viewpoints. viewpoints. viewpoints. viewpoints. viewpoints. viewpoints. viewpoints. viewpoints. Fear of retribution retribution retribution retribution retribution retribution retribution retribution retribution retribution retribution must be 

eliminated. The workforce needs a process to allow for dissent- eliminated. eliminated. eliminated. eliminated. eliminated. eliminated. eliminated. eliminated. eliminated. eliminated. The workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce needs a process process process process process process process process process process to allow for dissent- dissent- dissent- dissent- dissent- dissent- dissent- dissent- dissent- dissenting opinion and intervention when retribution or retaliation is ing opinion opinion opinion opinion opinion opinion opinion opinion opinion opinion and intervention intervention intervention intervention intervention intervention intervention intervention intervention intervention when retribution retribution retribution retribution retribution retribution retribution retribution retribution retribution or retaliation retaliation retaliation retaliation retaliation retaliation retaliation retaliation retaliation retaliation is 

suspected. The new Agency Ombuds, recommended by the Diaz suspected. suspected. suspected. suspected. suspected. suspected. suspected. suspected. suspected. suspected. The new Agency Ombuds, Ombuds, Ombuds, Ombuds, Ombuds, Ombuds, Ombuds, Ombuds, Ombuds, Ombuds, recommended recommended recommended recommended recommended recommended recommended recommended recommended recommended by the Diaz 

Team, should serve this purpose well. Team, should serve this purpose well. 

In addition to the actions in the Diaz Team Matrix that address In addition addition addition addition addition addition addition addition addition addition to the actions actions actions actions actions actions actions actions actions actions in the Diaz Team Matrix that address address address address address address address address address address 

each R-O-F, the Diaz Team has one goal addressing the Commu- each R-O-F, the Diaz Team has one goal addressing addressing addressing addressing addressing addressing addressing addressing addressing addressing addressing the Communication category, as shown in Table 4. nication category, as shown in Table 4.

Table 4. The Diaz Team developed one goal for Communication.

Communication – Diaz Team Goal

The Agency should continue the dialog that it began with the NASA workforce during Safety and Mission Success Week.
1 3

1.5 PROCESSES AND RULES

CAIB Report Chapter 8, p203:

When it came to managers’ own actions, however, a different set of rules prevailed. The Board found that Mission Management Team decision-making operated outside the rules even as it held its engineers to a stifl ing 

protocol. Management was not able to recognize that in unprecedented conditions, when lives are on the line, 

fl exibility and democratic process should take priority over bureaucratic response.

NASA has not followed its own rules.

Agency-wide Themes

• Requirements, policies, procedures, and directives must be examined and adhered to.

• Best practices and lessons learned must be 

incorporated.

• The entire workforce must be aware of and 

understand the rules.

Any complex organization must have processes and rules to con- Any complex complex complex complex complex complex complex complex complex complex complex complex organization ganization ganization ganization ganization ganization ganization ganization ganization ganization ganization ganization must have processes processes processes processes processes processes processes processes processes processes processes processes and rules to conduct its business. NASA is no exception. In a complex govern- duct its business. business. business. business. business. business. business. business. business. business. business. NASA is no exception. exception. exception. exception. exception. exception. exception. exception. exception. exception. exception. In a complex complex complex complex complex complex complex complex complex complex complex govern- govern- govern- govern- govern- govern- govern- govern- govern- govern- government organization such as NASA, many policies, requirements, ment organization ganization ganization ganization ganization ganization ganization ganization ganization ganization ganization ganization such as NASA, many policies, policies, policies, policies, policies, policies, policies, policies, policies, policies, policies, policies, requirements, requirements, requirements, requirements, requirements, requirements, requirements, requirements, requirements, requirements, requirements, requirements, 

and procedures are developed for employees to follow in the and procedures procedures procedures procedures procedures procedures procedures procedures procedures procedures procedures are developed developed developed developed developed developed developed developed developed developed developed for employees employees employees employees employees employees employees employees employees employees employees to follow in the 

conduct of programs, missions, designs, tests, and operations. conduct conduct conduct conduct conduct conduct conduct conduct conduct conduct conduct of programs, programs, programs, programs, programs, programs, programs, programs, programs, programs, programs, missions, missions, missions, missions, missions, missions, missions, missions, missions, missions, missions, designs, designs, designs, designs, designs, designs, designs, designs, designs, designs, designs, tests, and operations. operations. operations. operations. operations. operations. operations. operations. operations. operations. operations. 

Included in this category are the many processes for manag- Included Included Included Included Included Included Included Included Included Included Included in this category category category category category category category category category category category are the many processes processes processes processes processes processes processes processes processes processes processes for managing the external workforce of NASA through its large cadre of ing the external external external external external external external external external external external workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce of NASA through through through through through through through through through through through its large cadre of 

contractors. Many of these rules and processes were established contractors. contractors. contractors. contractors. contractors. contractors. contractors. contractors. contractors. contractors. contractors. contractors. Many of these rules and processes processes processes processes processes processes processes processes processes processes processes processes were established established established established established established established established established established established established 

as a result of adoption of best practices or lessons learned from as a result of adoption adoption adoption adoption adoption adoption adoption adoption adoption adoption adoption of best practices practices practices practices practices practices practices practices practices practices practices or lessons lessons lessons lessons lessons lessons lessons lessons lessons lessons lessons learned learned learned learned learned learned learned learned learned learned learned from 

program history. Some are the result of informal adoption into program program program program program program program program program program program program history history history history history history history history history history history history. Some are the result of informal informal informal informal informal informal informal informal informal informal informal informal adoption adoption adoption adoption adoption adoption adoption adoption adoption adoption adoption adoption into 

the culture of NASA – in essence – how NASA conducts its busi- the culture culture culture culture culture culture culture culture culture culture culture of NASA – in essence essence essence essence essence essence essence essence essence essence essence – how NASA conducts conducts conducts conducts conducts conducts conducts conducts conducts conducts conducts its business. Others may be confl icting among organizations, outdated, ness. Others may be conflicting among organizations, ganizations, ganizations, ganizations, ganizations, ganizations, ganizations, ganizations, ganizations, ganizations, ganizations, ganizations, outdated, outdated, outdated, outdated, outdated, outdated, outdated, outdated, outdated, outdated, outdated, outdated, 

or merely bureaucratic in nature offering little concrete benefi t. or merely bureaucratic bureaucratic bureaucratic bureaucratic bureaucratic bureaucratic bureaucratic bureaucratic bureaucratic bureaucratic bureaucratic in nature offering little concrete concrete concrete concrete concrete concrete concrete concrete concrete concrete concrete benefit. 

The CAIB examined NASAʼs processes and rules closely as it The CAIB examined examined examined examined examined examined examined examined examined examined examined NASAʼs processes processes processes processes processes processes processes processes processes processes processes and rules closely closely closely closely closely closely closely closely closely closely closely as it 

related to the Shuttle accident and arrived at some key conclu- related related related related related related related related related related related related to the Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle accident accident accident accident accident accident accident accident accident accident accident accident and arrived arrived arrived arrived arrived arrived arrived arrived arrived arrived arrived arrived at some key conclu- conclu- conclu- conclu- conclu- conclu- conclu- conclu- conclu- conclu- conclu- conclusions. 

Throughout the CAIB Report, a recurring observation was that Throughout Throughout Throughout Throughout Throughout Throughout Throughout Throughout Throughout Throughout Throughout the CAIB Report, Report, Report, Report, Report, Report, Report, Report, Report, Report, Report, a recurring recurring recurring recurring recurring recurring recurring recurring recurring recurring recurring observation observation observation observation observation observation observation observation observation observation observation was that 

NASA did not follow its own rules. The Board discovered orga- NASA did not follow its own rules. The Board discovered discovered discovered discovered discovered discovered discovered discovered discovered discovered discovered discovered organizational practices detrimental to safety and reliability including nizational nizational nizational nizational nizational nizational nizational nizational nizational nizational nizational practices practices practices practices practices practices practices practices practices practices practices detrimental detrimental detrimental detrimental detrimental detrimental detrimental detrimental detrimental detrimental detrimental to safety and reliability reliability reliability reliability reliability reliability reliability reliability reliability reliability reliability including including including including including including including including including including including 

the “evolution of an informal chain of command and decision- the “evolution “evolution “evolution “evolution “evolution “evolution “evolution “evolution “evolution “evolution “evolution of an informal informal informal informal informal informal informal informal informal informal informal chain of command command command command command command command command command command command and decision- decision- decision- decision- decision- decision- decision- decision- decision- decision- decisionmaking processes that operated outside the organizationʼs rules.” making processes processes processes processes processes processes processes processes processes processes processes that operated operated operated operated operated operated operated operated operated operated operated outside outside outside outside outside outside outside outside outside outside outside the organizationʼ ganizationʼ ganizationʼ ganizationʼ ganizationʼ ganizationʼ ganizationʼ ganizationʼ ganizationʼ ganizationʼ ganizationʼs rules.” rules.” rules.” rules.” rules.” rules.” rules.” rules.” rules.” rules.” rules.” 

Yet, the Board believed rules which were followed within NASA Yet, the Board believed believed believed believed believed believed believed believed believed believed believed rules which were followed followed followed followed followed followed followed followed followed followed followed within NASA

were often more bureaucratic and had the effect of stifl ing critical were often more bureaucratic bureaucratic bureaucratic bureaucratic bureaucratic bureaucratic bureaucratic bureaucratic bureaucratic bureaucratic bureaucratic bureaucratic and had the effect of stifling critical critical critical critical critical critical critical critical critical critical critical critical 

communication. 

After evaluating the CAIB Report and the Safety and Mission After evaluating evaluating evaluating evaluating evaluating evaluating evaluating evaluating evaluating evaluating evaluating the CAIB Report and the Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission 

Success Week feedback, the Diaz Team has concluded that many Success Success Success Success Success Success Success Success Success Success Success Success Week feedback, feedback, feedback, feedback, feedback, feedback, feedback, feedback, feedback, feedback, feedback, feedback, the Diaz Team has concluded concluded concluded concluded concluded concluded concluded concluded concluded concluded concluded concluded that many 

in the workforce do not understand the policies and rules they are in the workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce do not understand understand understand understand understand understand understand understand understand understand understand the policies policies policies policies policies policies policies policies policies policies policies and rules they are 

required to adhere to. 

The CAIB Report had this to say about rules:

Cultural traits and organizational practices detrimental Cultural Cultural Cultural Cultural Cultural Cultural Cultural Cultural Cultural Cultural traits and organizational organizational organizational organizational organizational organizational organizational organizational organizational organizational practices practices practices practices practices practices practices practices practices practices detrimental detrimental detrimental detrimental detrimental detrimental detrimental detrimental detrimental detrimental 

to safety were allowed to develop, including... lack of to safety were allowed allowed allowed allowed allowed allowed allowed allowed allowed to develop, develop, develop, develop, develop, develop, develop, develop, develop, including... including... including... including... including... including... including... including... including... lack of 

integrated management across program elements... and integrated integrated integrated integrated integrated integrated integrated integrated integrated integrated management management management management management management management management management management across program program program program program program program program program program elements... elements... elements... elements... elements... elements... elements... elements... elements... elements... and 

the evolution of an informal chain of command and deci- the evolution evolution evolution evolution evolution evolution evolution evolution evolution of an informal informal informal informal informal informal informal informal informal chain of command command command command command command command command command and decision-making processes that operated outside the organi- sion-making sion-making sion-making sion-making sion-making sion-making sion-making sion-making sion-making sion-making processes processes processes processes processes processes processes processes processes processes that operated operated operated operated operated operated operated operated operated operated outside outside outside outside outside outside outside outside outside outside the organi- organi- organi- organi- organi- organi- organi- organi- organi- organization’s rules. (CAIB, Executive Summary, p. 9) zation’s rules. (CAIB, Executive Summary, p. 9)

The way in which NASA develops and executes its rules and The way in which NASA develops develops develops develops develops develops develops develops develops develops develops develops and executes executes executes executes executes executes executes executes executes executes executes executes its rules and 

processes embodies a fundamental cultural trait for the Agency. processes processes processes processes processes processes processes processes processes processes processes embodies embodies embodies embodies embodies embodies embodies embodies embodies embodies embodies a fundamental fundamental fundamental fundamental fundamental fundamental fundamental fundamental fundamental fundamental fundamental cultural cultural cultural cultural cultural cultural cultural cultural cultural cultural cultural trait for the Agency. 

Organizations that deal with high-risk technology must develop Organizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations that deal with high-risk high-risk high-risk high-risk high-risk high-risk high-risk high-risk high-risk high-risk high-risk high-risk technology technology technology technology technology technology technology technology technology technology technology technology must develop develop develop develop develop develop develop develop develop develop develop develop 

a best practices culture in order to operate safely and reliably. To a best practices practices practices practices practices practices practices practices practices practices practices culture culture culture culture culture culture culture culture culture culture culture in order to operate operate operate operate operate operate operate operate operate operate operate safely and reliably reliably reliably reliably reliably reliably reliably reliably reliably reliably reliably. To 

achieve this within NASA, all programs must develop rules that achieve achieve achieve achieve achieve achieve achieve achieve achieve achieve achieve achieve this within NASA, all programs programs programs programs programs programs programs programs programs programs programs programs must develop develop develop develop develop develop develop develop develop develop develop develop rules that 

lead to increased communication and enhanced decision-mak- lead to increased increased increased increased increased increased increased increased increased increased increased communication communication communication communication communication communication communication communication communication communication communication and enhanced enhanced enhanced enhanced enhanced enhanced enhanced enhanced enhanced enhanced enhanced decision-mak- decision-mak- decision-mak- decision-mak- decision-mak- decision-mak- decision-mak- decision-mak- decision-mak- decision-mak- decision-making.

The observations and fi ndings of the CAIB also revealed a need The observations observations observations observations observations observations observations observations observations observations observations and findings of the CAIB also revealed revealed revealed revealed revealed revealed revealed revealed revealed revealed revealed a need 

for NASA to examine its processes, make changes where appro- for NASA to examine examine examine examine examine examine examine examine examine examine examine examine its processes, processes, processes, processes, processes, processes, processes, processes, processes, processes, processes, processes, make changes changes changes changes changes changes changes changes changes changes changes changes where appropriate, and apply the processes uniformly across programs. The priate, priate, priate, priate, priate, priate, priate, priate, priate, priate, priate, and apply the processes processes processes processes processes processes processes processes processes processes processes uniformly uniformly uniformly uniformly uniformly uniformly uniformly uniformly uniformly uniformly uniformly across programs. programs. programs. programs. programs. programs. programs. programs. programs. programs. programs. The 

Board, in essence, stated that NASA must set required processes Board, in essence, essence, essence, essence, essence, essence, essence, essence, essence, essence, essence, essence, stated that NASA must set required required required required required required required required required required required required processes processes processes processes processes processes processes processes processes processes processes processes 

that ensure accurate and timely information fl ow and then “fol- that ensure accurate accurate accurate accurate accurate accurate accurate accurate accurate accurate accurate and timely information information information information information information information information information information information flow and then “follow the rules” established for making decisions with this data. low the rules” established established established established established established established established established established established established for making decisions decisions decisions decisions decisions decisions decisions decisions decisions decisions decisions decisions with this data. 

While many of the 40 actions in the Diaz Team Matrix require While many of the 40 actions actions actions actions actions actions actions actions actions actions actions in the Diaz Team Matrix require require require require require require require require require require require 

that the policies governing the R-O-F area be reviewed and mod- that the policies policies policies policies policies policies policies policies policies policies policies governing governing governing governing governing governing governing governing governing governing governing the R-O-F area be reviewed reviewed reviewed reviewed reviewed reviewed reviewed reviewed reviewed reviewed reviewed and modifi ed if necessary, a complete review of policies and directives in ified if necessary necessary necessary necessary necessary necessary necessary necessary necessary necessary necessary necessary, a complete complete complete complete complete complete complete complete complete complete complete complete review of policies policies policies policies policies policies policies policies policies policies policies policies and directives directives directives directives directives directives directives directives directives directives directives directives in 

the Agency should be conducted. the Agency should be conducted.

The feedback from Safety and Mission Success Week reinforced The feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback from Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Success Success Success Success Success Success Success Success Success Success Success Week reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced 

the Diaz Team assessment: the Diaz Team assessment:

» We say all the right language and have all the right We say all the right language and have all the right 

procedures, but donʼt follow them. procedures, but donʼt follow them.

» When internal and contracted requirements are not 

fi rmly established, employees can feel that nothing is firmly established, employees can feel that nothing is 

mandatory. mandatory. 

» Crew Resource Management is a process used in other 

industries that can be applied across NASA and in industries that can be applied across NASA and in 

particular mission-critical management positions. 

In addition to the actions in the Diaz Team Matrix that address In addition addition addition addition addition addition addition addition addition addition addition to the actions actions actions actions actions actions actions actions actions actions actions in the Diaz Team Matrix that address address address address address address address address address address address 

each R-O-F, the Diaz Team has one goal addressing the Pro- each R-O-F, the Diaz Team has one goal addressing addressing addressing addressing addressing addressing addressing addressing addressing addressing addressing the Processes and Rules category, as shown in Table 5. cesses and Rules category, as shown in Table 5.

Table 5. The Diaz Team developed one goal for Processes and Rules.

Processes and Rules – Diaz Team Goal

The Agency should conduct a review of its approach to maintaining and managing rules.
1 4

1.6 TECHNICAL CAPABILITIES

CAIB Report Chapter 7, p179:

As a result [of the Space Flight Operations Contract], experienced engineers changed jobs, NASA grew dependent on contractors for technical support, contract monitoring requirements increased, and positions were 

subsequently staffed by less experienced engineers who were placed in management roles. Collectively, this 

eroded NASA’s in-house engineering and technical capabilities.

NASA’s in-house capabilities and expertise have 

eroded.

Agency-wide Themes

• Analytical models and simulation tools must be 

used appropriately.

• NASA must address the loss of technical expertise due to retirement and outsourcing.

• Advanced technical capabilities must be 

developed.

NASA has always viewed itself as a cutting-edge technology NASA has always viewed itself as a cutting-edge cutting-edge cutting-edge cutting-edge cutting-edge cutting-edge cutting-edge cutting-edge cutting-edge cutting-edge cutting-edge technology technology technology technology technology technology technology technology technology technology technology 

organization, with accomplished scientists and engineers devel- organization, ganization, ganization, ganization, ganization, ganization, ganization, ganization, ganization, ganization, ganization, ganization, with accomplished accomplished accomplished accomplished accomplished accomplished accomplished accomplished accomplished accomplished accomplished accomplished scientists scientists scientists scientists scientists scientists scientists scientists scientists scientists scientists scientists and engineers engineers engineers engineers engineers engineers engineers engineers engineers engineers engineers engineers developing and applying the most modern of technology tools. During oping and applying applying applying applying applying applying applying applying applying applying applying the most modern of technology technology technology technology technology technology technology technology technology technology technology tools. During 

the investigation of the the investigation of the Columbia accident, the CAIB came to accident, accident, accident, accident, accident, the CAIB came to 

believe otherwise. There was evidence of erosion in NASAʼs believe believe believe believe believe believe believe believe believe believe believe otherwise. otherwise. otherwise. otherwise. otherwise. otherwise. otherwise. otherwise. otherwise. otherwise. otherwise. There was evidence evidence evidence evidence evidence evidence evidence evidence evidence evidence evidence of erosion erosion erosion erosion erosion erosion erosion erosion erosion erosion erosion in NASAʼs 

technological capabilities and expertise within the Shuttle Pro- technological technological technological technological technological technological technological technological technological technological technological capabilities capabilities capabilities capabilities capabilities capabilities capabilities capabilities capabilities capabilities capabilities and expertise expertise expertise expertise expertise expertise expertise expertise expertise expertise expertise within the Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Program. The CAIB found problems with the use of modern tools gram. The CAIB found problems problems problems problems problems problems problems problems problems problems problems problems with the use of modern tools 

and methods for information management. Research organiza- and methods methods methods methods methods methods methods methods methods methods methods for information information information information information information information information information information information management. management. management. management. management. management. management. management. management. management. management. Research Research Research Research Research Research Research Research Research Research Research organiza- ganiza- ganiza- ganiza- ganiza- ganiza- ganiza- ganiza- ganiza- ganiza- ganizations today rely on modeling, simulation, design, and analytical tions today rely on modeling, modeling, modeling, modeling, modeling, modeling, modeling, modeling, modeling, modeling, modeling, modeling, simulation, simulation, simulation, simulation, simulation, simulation, simulation, simulation, simulation, simulation, simulation, simulation, design, design, design, design, design, design, design, design, design, design, design, design, and analytical analytical analytical analytical analytical analytical analytical analytical analytical analytical analytical analytical 

tools. At NASA, the CAIB found ineffective and inconsistent ac- tools. At NASA, the CAIB found ineffective fective fective fective fective fective fective fective fective fective fective and inconsistent inconsistent inconsistent inconsistent inconsistent inconsistent inconsistent inconsistent inconsistent inconsistent inconsistent access to these tools, along with cases of outright misuse. Some of cess to these tools, along with cases of outright outright outright outright outright outright outright outright outright outright outright outright misuse. misuse. misuse. misuse. misuse. misuse. misuse. misuse. misuse. misuse. misuse. misuse. Some of 

this stemmed from a lack of technical understanding. The CAIB this stemmed stemmed stemmed stemmed stemmed stemmed stemmed stemmed stemmed stemmed stemmed from a lack of technical technical technical technical technical technical technical technical technical technical technical understanding. understanding. understanding. understanding. understanding. understanding. understanding. understanding. understanding. understanding. understanding. The CAIB 

Report stated it this way:

As a result [of the Space Flight Operations Contract], As a result [of the Space Flight Operations Operations Operations Operations Operations Operations Operations Operations Operations Contract], Contract], Contract], Contract], Contract], Contract], Contract], Contract], Contract], 

experienced engineers changed jobs, NASA grew de- experienced experienced experienced experienced experienced experienced experienced experienced experienced experienced engineers engineers engineers engineers engineers engineers engineers engineers engineers engineers changed changed changed changed changed changed changed changed changed changed jobs, NASA grew dependent on contractors for technical support, contract pendent pendent pendent pendent pendent pendent pendent pendent pendent on contractors contractors contractors contractors contractors contractors contractors contractors contractors for technical technical technical technical technical technical technical technical technical support, support, support, support, support, support, support, support, support, contract contract contract contract contract contract contract contract contract 

monitoring requirements increased, and positions were monitoring monitoring monitoring monitoring monitoring monitoring monitoring monitoring monitoring monitoring requirements requirements requirements requirements requirements requirements requirements requirements requirements requirements increased, increased, increased, increased, increased, increased, increased, increased, increased, increased, and positions positions positions positions positions positions positions positions positions positions were 

subsequently staffed by less experienced engineers subsequently subsequently subsequently subsequently subsequently subsequently subsequently subsequently subsequently staffed by less experienced experienced experienced experienced experienced experienced experienced experienced experienced engineers engineers engineers engineers engineers engineers engineers engineers engineers 

who were placed in management roles. Collectively, this who were placed in management management management management management management management management management management roles. Collectively Collectively Collectively Collectively Collectively Collectively Collectively Collectively Collectively Collectively, this 

eroded NASA’s in-house engineering and technical capa- eroded NASA’s in-house in-house in-house in-house in-house in-house in-house in-house in-house engineering engineering engineering engineering engineering engineering engineering engineering engineering and technical technical technical technical technical technical technical technical technical capabilities.... (CAIB Report, Chapter 7, p. 179)

Due to limited resources and current Agency operation philoso- Due to limited limited limited limited limited limited limited limited limited limited limited resources resources resources resources resources resources resources resources resources resources resources and current current current current current current current current current current current Agency operation operation operation operation operation operation operation operation operation operation operation philoso- philoso- philoso- philoso- philoso- philoso- philoso- philoso- philoso- philoso- philosophies, NASA has come to rely on contractors to perform engi- phies, NASA has come to rely on contractors contractors contractors contractors contractors contractors contractors contractors contractors contractors contractors contractors to perform perform perform perform perform perform perform perform perform perform perform perform engineering functions on its projects. In addition, downsizing without neering neering neering neering neering neering neering neering neering neering neering functions functions functions functions functions functions functions functions functions functions functions on its projects. projects. projects. projects. projects. projects. projects. projects. projects. projects. projects. In addition, addition, addition, addition, addition, addition, addition, addition, addition, addition, addition, downsizing downsizing downsizing downsizing downsizing downsizing downsizing downsizing downsizing downsizing downsizing without without without without without without without without without without without 

replenishment of critical skills over the past decade has further replenishment replenishment replenishment replenishment replenishment replenishment replenishment replenishment replenishment replenishment replenishment replenishment of critical critical critical critical critical critical critical critical critical critical critical critical skills over the past decade has further further further further further further further further further further further further 

contributed to a skill imbalance that is liable to be exacerbated contributed contributed contributed contributed contributed contributed contributed contributed contributed contributed contributed to a skill imbalance imbalance imbalance imbalance imbalance imbalance imbalance imbalance imbalance imbalance imbalance that is liable to be exacerbated exacerbated exacerbated exacerbated exacerbated exacerbated exacerbated exacerbated exacerbated exacerbated exacerbated 

by future retirements. The above conditions, occurring across the by future retirements. retirements. retirements. retirements. retirements. retirements. retirements. retirements. retirements. retirements. retirements. The above conditions, conditions, conditions, conditions, conditions, conditions, conditions, conditions, conditions, conditions, conditions, occurring occurring occurring occurring occurring occurring occurring occurring occurring occurring occurring across the 

entire Agency, has resulted in a decline in NASAʼs technical ca- entire Agency, has resulted resulted resulted resulted resulted resulted resulted resulted resulted resulted resulted in a decline decline decline decline decline decline decline decline decline decline decline in NASAʼs technical technical technical technical technical technical technical technical technical technical technical capabilities and competencies in its civil service workforce, and the pabilities pabilities pabilities pabilities pabilities pabilities pabilities pabilities pabilities pabilities pabilities and competencies competencies competencies competencies competencies competencies competencies competencies competencies competencies competencies in its civil service service service service service service service service service service service workforce, workforce, workforce, workforce, workforce, workforce, workforce, workforce, workforce, workforce, workforce, and the 

over-reliance on developmental and operational contractors. over-reliance on developmental and operational contractors.

The theme of the two CAIB recommendations related to tech- The theme of the two CAIB recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations related related related related related related related related related related related to technical capabilities implies the Agency-wide need for technical nical capabilities capabilities capabilities capabilities capabilities capabilities capabilities capabilities capabilities capabilities implies implies implies implies implies implies implies implies implies implies the Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide need for technical technical technical technical technical technical technical technical technical technical 

capacity to maintain documentation and databases and the need capacity capacity capacity capacity capacity capacity capacity capacity capacity capacity capacity to maintain maintain maintain maintain maintain maintain maintain maintain maintain maintain maintain documentation documentation documentation documentation documentation documentation documentation documentation documentation documentation documentation and databases databases databases databases databases databases databases databases databases databases databases and the need 

to implement knowledge management practices and capabilities to implement implement implement implement implement implement implement implement implement implement knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge management management management management management management management management management management practices practices practices practices practices practices practices practices practices practices and capabilities capabilities capabilities capabilities capabilities capabilities capabilities capabilities capabilities capabilities 

NASA-wide that are critical to technical management and deci- NASA-wide NASA-wide NASA-wide NASA-wide NASA-wide NASA-wide NASA-wide NASA-wide NASA-wide NASA-wide NASA-wide that are critical critical critical critical critical critical critical critical critical critical critical to technical technical technical technical technical technical technical technical technical technical technical management management management management management management management management management management management and decision-making. When evaluated from an Agency-wide perspective, sion-making. sion-making. sion-making. sion-making. sion-making. sion-making. sion-making. sion-making. sion-making. sion-making. When evaluated evaluated evaluated evaluated evaluated evaluated evaluated evaluated evaluated evaluated from an Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide perspective, perspective, perspective, perspective, perspective, perspective, perspective, perspective, perspective, perspective, 

it is clear that all NASA programs need validated models and an- it is clear that all NASA programs programs programs programs programs programs programs programs programs programs programs need validated validated validated validated validated validated validated validated validated validated validated models and analytical tools to assess the state of their systems and components. alytical alytical alytical alytical alytical alytical alytical alytical alytical alytical tools to assess the state of their systems systems systems systems systems systems systems systems systems systems and components. components. components. components. components. components. components. components. components. components. 

This will enable enhanced decision-making. Moreover, this im- This will enable enhanced enhanced enhanced enhanced enhanced enhanced enhanced enhanced enhanced enhanced decision-making. decision-making. decision-making. decision-making. decision-making. decision-making. decision-making. decision-making. decision-making. decision-making. Moreover Moreover Moreover Moreover Moreover Moreover Moreover Moreover Moreover Moreover, this implies a need to further develop technological competency within plies a need to further further further further further further further further further further further develop develop develop develop develop develop develop develop develop develop develop technological technological technological technological technological technological technological technological technological technological technological competency competency competency competency competency competency competency competency competency competency competency within 

the Agency to effectively and consistently apply, maintain, and the Agency to effectively fectively fectively fectively fectively fectively fectively fectively fectively fectively and consistently consistently consistently consistently consistently consistently consistently consistently consistently consistently apply, maintain, maintain, maintain, maintain, maintain, maintain, maintain, maintain, maintain, maintain, and 

update these models and tools. One way to achieve this techno- update these models and tools. One way to achieve achieve achieve achieve achieve achieve achieve achieve achieve achieve achieve this techno- techno- techno- techno- techno- techno- techno- techno- techno- techno- technological competency is to increase investment in the development logical logical logical logical logical logical logical logical logical logical competency competency competency competency competency competency competency competency competency competency is to increase increase increase increase increase increase increase increase increase increase investment investment investment investment investment investment investment investment investment investment in the development development development development development development development development development development 

and training of NASAʼs scientifi c and engineering workforce in and training training training training training training training training training training training of NASAʼs scientifi scientifi scientifi scientifi scientifi scientifi scientifi scientifi scientifi scientifi scientific and engineering engineering engineering engineering engineering engineering engineering engineering engineering engineering engineering workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce in 

order to increase their skill base and overall effectiveness. order to increase their skill base and overall effectiveness.

The feedback from Safety and Mission Success Week reinforced The feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback from Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Success Success Success Success Success Success Success Success Success Success Week reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced 

the Diaz Team assessment: the Diaz Team assessment:

» Technical expertise is being lost within NASA due to Technical expertise is being lost within NASA due to 

retirement and the outsourcing of technical profi ciency retirement and the outsourcing of technical proficiency 

to contractors. 

» There is a need to have more decision-makers with 

hands-on experience in addition to theoretical knowledge. 

» Technical expertise needs improvement throughout Technical expertise needs improvement throughout 

NASA.

» Technical tools and information systems are not there Technical tools and information systems are not there 

for people to effectively do their jobs. for people to effectively do their jobs. 

NASA has taken steps recently to develop systems to identify NASA has taken steps recently recently recently recently recently recently recently recently recently recently to develop develop develop develop develop develop develop develop develop develop systems systems systems systems systems systems systems systems systems systems to identify identify identify identify identify identify identify identify identify identify 

critical competencies across the Agency. NASA should go fur- critical critical critical critical critical critical critical critical critical critical critical competencies competencies competencies competencies competencies competencies competencies competencies competencies competencies competencies across the Agency. NASA should go further and develop strategies of continuous investment and prac- ther and develop develop develop develop develop develop develop develop develop develop strategies strategies strategies strategies strategies strategies strategies strategies strategies strategies of continuous continuous continuous continuous continuous continuous continuous continuous continuous continuous investment investment investment investment investment investment investment investment investment investment and practice for assuring that required competencies are maintained and tice for assuring assuring assuring assuring assuring assuring assuring assuring assuring assuring that required required required required required required required required required required competencies competencies competencies competencies competencies competencies competencies competencies competencies competencies are maintained maintained maintained maintained maintained maintained maintained maintained maintained maintained and 

applied to activities in an appropriate way. The future ability to applied applied applied applied applied applied applied applied applied applied applied to activities activities activities activities activities activities activities activities activities activities activities in an appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate way. The future ability ability ability ability ability ability ability ability ability ability ability to 

make technically credible design, test, operational, and safety de- make technically technically technically technically technically technically technically technically technically technically credible credible credible credible credible credible credible credible credible credible design, design, design, design, design, design, design, design, design, design, test, operational, operational, operational, operational, operational, operational, operational, operational, operational, operational, and safety decisions will rely on NASA systematically improving its technical cisions cisions cisions cisions cisions cisions cisions cisions cisions cisions cisions will rely on NASA systematically systematically systematically systematically systematically systematically systematically systematically systematically systematically systematically improving improving improving improving improving improving improving improving improving improving improving its technical technical technical technical technical technical technical technical technical technical technical 

capabilities and competencies throughout the Agency. capabilities and competencies throughout the Agency.

In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address 

each R-O-F, the Diaz Team has one goal addressing the Techni- each R-O-F each R-O-F each R-O-F each R-O-F each R-O-F each R-O-F each R-O-F each R-O-F each R-O-F each R-O-F, the Diaz , the Diaz , the Diaz , the Diaz , the Diaz , the Diaz , the Diaz , the Diaz , the Diaz , the Diaz Team has one goal addressing the eam has one goal addressing the eam has one goal addressing the eam has one goal addressing the eam has one goal addressing the eam has one goal addressing the eam has one goal addressing the eam has one goal addressing the eam has one goal addressing the eam has one goal addressing the Technical Capabilities category, as shown in Table 6. cal Capabilities category, as shown in Table 6.

Table 6. The Diaz Team developed one goal for Technical Capabilities.

Technical Capabilities – Diaz Team Goal

The Agency should develop guidelines and metrics for assessing and maintaining its core competencies, including those associated 

with in-house work.
1 5

1.7 ORGANIZATIONAL STRUCTURE

CAIB Report Executive Summary, p9:

This report discusses the attributes of an organization that could more safely and reliably operate the inherently 

risky Space Shuttle, but does not provide a detailed organizational prescription. Among those attributes are: a 

robust and independent program technical authority that has complete control over specifi cations and requirements, and waivers to them; an independent safety assurance organization with line authority over all levels of 

safety oversight; and an organizational culture that refl ects the best characteristics of a learning organization.

NASA’s safety and engineering organizations lack 

authority and independence.

Agency-wide Themes

• NASA must ensure systematic checks-and-balances are in place.

• NASA must implement independent safety and 

technical organizations.

• Roles and responsibilities must be clearly defi ned and widely understood.

The Diaz Team felt strongly that changes suggested by the CAIB The Diaz Team felt strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly strongly that changes changes changes changes changes changes changes changes changes changes changes changes suggested suggested suggested suggested suggested suggested suggested suggested suggested suggested suggested suggested by the CAIB 

for the Space Shuttle Program were worth serious consideration for the Space Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Program Program Program Program Program Program Program Program Program Program Program were worth serious serious serious serious serious serious serious serious serious serious serious consideration consideration consideration consideration consideration consideration consideration consideration consideration consideration consideration 

throughout NASA. These changes were observed by the CAIB throughout throughout throughout throughout throughout throughout throughout throughout throughout throughout throughout NASA. These changes changes changes changes changes changes changes changes changes changes changes were observed observed observed observed observed observed observed observed observed observed observed by the CAIB 

to be needed in NASAʼs organizational approach to allow for a to be needed in NASAʼs organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational approach approach approach approach approach approach approach approach approach approach approach to allow for a 

healthy “check-and-balance” system to prevail. 

The CAIB Report had the following to say about the need for The CAIB Report had the following following following following following following following following following following following to say about the need for 

such controls:

When high-risk technology is the product and lives are When high-risk high-risk high-risk high-risk high-risk high-risk high-risk high-risk high-risk high-risk technology technology technology technology technology technology technology technology technology technology is the product product product product product product product product product product and lives are 

at stake, safety, oversight, and communication fl ows are at stake, safety, oversight, oversight, oversight, oversight, oversight, oversight, oversight, oversight, oversight, and communication communication communication communication communication communication communication communication communication flows are 

critical. The Board found that the Shuttle Program’s nor- critical. critical. critical. critical. critical. critical. critical. critical. critical. The Board found that the Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Program’ Program’ Program’ Program’ Program’ Program’ Program’ Program’ Program’s normal chain of command and matrix system did not perform mal chain of command command command command command command command command command command and matrix system did not perform perform perform perform perform perform perform perform perform perform 

a check-and-balance function on either foam or O-rings. a check-and-balance check-and-balance check-and-balance check-and-balance check-and-balance check-and-balance check-and-balance check-and-balance check-and-balance function function function function function function function function function on either foam or O-rings. O-rings. O-rings. O-rings. O-rings. O-rings. O-rings. O-rings. O-rings. 

(CAIB Report, Chapter 8, p. 198)

NASA must implement CAIB-suggested organizational struc- NASA must implement implement implement implement implement implement implement implement implement implement implement implement CAIB-suggested CAIB-suggested CAIB-suggested CAIB-suggested CAIB-suggested CAIB-suggested CAIB-suggested CAIB-suggested CAIB-suggested CAIB-suggested CAIB-suggested CAIB-suggested organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational structure changes. The current check-and-balance infrastructure is ture changes. changes. changes. changes. changes. changes. changes. changes. changes. changes. changes. The current current current current current current current current current current current check-and-balance check-and-balance check-and-balance check-and-balance check-and-balance check-and-balance check-and-balance check-and-balance check-and-balance check-and-balance check-and-balance infrastructure infrastructure infrastructure infrastructure infrastructure infrastructure infrastructure infrastructure infrastructure infrastructure infrastructure is 

inadequate. The CAIBʼs answer to this issue was to create an inadequate. inadequate. inadequate. inadequate. inadequate. inadequate. inadequate. inadequate. inadequate. inadequate. inadequate. inadequate. The CAIBʼs answer to this issue was to create an 

Independent Technical Engineering Authority (ITEA) as a new Independent Independent Independent Independent Independent Independent Independent Independent Independent Independent Independent Technical echnical echnical echnical echnical echnical echnical echnical echnical echnical echnical Engineering Engineering Engineering Engineering Engineering Engineering Engineering Engineering Engineering Engineering Engineering Authority Authority Authority Authority Authority Authority Authority Authority Authority Authority Authority (ITEA) as a new 

key structural component within NASA for the Space Shuttle key structural structural structural structural structural structural structural structural structural structural structural component component component component component component component component component component component within NASA for the Space Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle 

Program. The specifi c authority and responsibilities of that ITEA Program. Program. Program. Program. Program. Program. Program. Program. Program. Program. Program. Program. The specifi specic authority authority authority authority authority authority authority authority authority authority authority authority and responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities of that ITEA

must be developed in accordance with the CAIB. However, the must be developed developed developed developed developed developed developed developed developed developed developed in accordance accordance accordance accordance accordance accordance accordance accordance accordance accordance accordance with the CAIB. However However However However However However However However However However However, the 

Diaz Team concluded that all programs would benefi t from an Diaz Team concluded concluded concluded concluded concluded concluded concluded concluded concluded concluded concluded concluded that all programs programs programs programs programs programs programs programs programs programs programs programs would benefit from an 

independent engineering authority concept that is applied across independent independent independent independent independent independent independent independent independent independent independent engineering engineering engineering engineering engineering engineering engineering engineering engineering engineering engineering authority authority authority authority authority authority authority authority authority authority authority concept concept concept concept concept concept concept concept concept concept concept that is applied applied applied applied applied applied applied applied applied applied applied across 

the Agency, to ensure that technical standards are being met. the Agency, to ensure that technical technical technical technical technical technical technical technical technical technical technical technical standards standards standards standards standards standards standards standards standards standards standards standards are being met. 

Therefore, the Team recommends that an independent technical Therefore, Therefore, Therefore, Therefore, Therefore, Therefore, Therefore, Therefore, Therefore, Therefore, Therefore, the Team recommends recommends recommends recommends recommends recommends recommends recommends recommends recommends recommends that an independent independent independent independent independent independent independent independent independent independent independent technical technical technical technical technical technical technical technical technical technical technical 

authority concept be applied on all technical programs. As rec- authority authority authority authority authority authority authority authority authority authority authority concept concept concept concept concept concept concept concept concept concept concept be applied applied applied applied applied applied applied applied applied applied applied on all technical technical technical technical technical technical technical technical technical technical technical programs. programs. programs. programs. programs. programs. programs. programs. programs. programs. programs. As recommended in the CAIB R7.5-1, the ITEA must, at a minimum: ommended ommended ommended ommended ommended ommended ommended ommended ommended ommended ommended in the CAIB R7.5-1, R7.5-1, R7.5-1, R7.5-1, R7.5-1, R7.5-1, R7.5-1, R7.5-1, R7.5-1, R7.5-1, R7.5-1, the ITEA must, at a minimum: minimum: minimum: minimum: minimum: minimum: minimum: minimum: minimum: minimum: minimum: 

develop and maintain, and be the sole waiver-granting authority develop develop develop develop develop develop develop develop develop develop develop and maintain, maintain, maintain, maintain, maintain, maintain, maintain, maintain, maintain, maintain, maintain, and be the sole waiver-granting -granting -granting -granting -granting -granting -granting -granting -granting -granting -granting authority authority authority authority authority authority authority authority authority authority authority 

for all technical standards; conduct trend and risk analyses and for all technical technical technical technical technical technical technical technical technical technical technical technical standards; standards; standards; standards; standards; standards; standards; standards; standards; standards; standards; standards; conduct conduct conduct conduct conduct conduct conduct conduct conduct conduct conduct conduct trend and risk analyses analyses analyses analyses analyses analyses analyses analyses analyses analyses analyses analyses and 

own the failure mode, effects analyses, and hazard reporting sys- own the failure failure failure failure failure failure failure failure failure failure failure mode, effects analyses, analyses, analyses, analyses, analyses, analyses, analyses, analyses, analyses, analyses, analyses, and hazard reporting reporting reporting reporting reporting reporting reporting reporting reporting reporting reporting systems; and decide what is and what is not an anomalous event. 

The feedback from Safety and Mission Success Week reinforced The feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback from Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Success Success Success Success Success Success Success Success Success Success Success Success Week reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced 

the Diaz Team assessment: the Diaz Team assessment:

» Have our leadership thoroughly evaluate the system of 

safety and mission success with regard to the plethora 

of organizations having responsibility for oversee- of organizations having responsibility for overseeing the safety and quality of work performed with the 

express intent of making it simpler, safer and higher express intent of making it simpler, safer and higher 

quality/reliability while reducing the overlapping 

responsibilities.

» Organizations must be structured to provide a more Organizations must be structured to provide a more 

effective balance between program schedule/cost man- effective balance between program schedule/cost management and technical review authority. agement and technical review authority.

» NASA should look to eliminate or modify organi- NASA should look to eliminate or modify organizational distinctions that create divisions within the 

Agency, which potentially foster competition rather Agency, which potentially foster competition rather 

than collaboration.

» Clearly defi ne roles, responsibilities, and accountabil- Clearly define roles, responsibilities, and accountability starting with the role of the Agency/Center, then ity starting with the role of the Agency/Center, then 

on down, to describe strategically what we want to do, 

who will do it, and who is responsible for what. 

NASA should seriously consider CAIB-suggested organiza- NASA should seriously seriously seriously seriously seriously seriously seriously seriously seriously seriously seriously consider consider consider consider consider consider consider consider consider consider consider CAIB-suggested CAIB-suggested CAIB-suggested CAIB-suggested CAIB-suggested CAIB-suggested CAIB-suggested CAIB-suggested CAIB-suggested CAIB-suggested CAIB-suggested organiza- ganiza- ganiza- ganiza- ganiza- ganiza- ganiza- ganiza- ganiza- ganiza- ganizational structure changes across the Agency. The organizational tional structure structure structure structure structure structure structure structure structure structure structure structure changes changes changes changes changes changes changes changes changes changes changes changes across the Agency. The organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational 

structure can help clarify roles and responsibilities of individual structure structure structure structure structure structure structure structure structure structure structure can help clarify clarify clarify clarify clarify clarify clarify clarify clarify clarify clarify roles and responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities of individual individual individual individual individual individual individual individual individual individual individual 

employees, work groups, and leadership. In transitioning to the employees, employees, employees, employees, employees, employees, employees, employees, employees, employees, employees, employees, work groups, groups, groups, groups, groups, groups, groups, groups, groups, groups, groups, groups, and leadership. leadership. leadership. leadership. leadership. leadership. leadership. leadership. leadership. leadership. leadership. leadership. In transitioning transitioning transitioning transitioning transitioning transitioning transitioning transitioning transitioning transitioning transitioning transitioning to the 

new organization, every member of the workforce should be able new organization, ganization, ganization, ganization, ganization, ganization, ganization, ganization, ganization, ganization, ganization, every member of the workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce should be able 

to answer three basic questions:

• Do you know where you fi t in the organizational struc- Do you know where you fit in the organizational structure?

• Do you know to whom you report, and who reports to 

you?

• Do you know your responsibility, authority, and ac- Do you know your responsibility, authority, and accountability?

A healthy organizational structure is a solid foundation to help A healthy healthy healthy healthy healthy healthy healthy healthy healthy healthy healthy healthy organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational structure structure structure structure structure structure structure structure structure structure structure structure is a solid foundation foundation foundation foundation foundation foundation foundation foundation foundation foundation foundation foundation to help 

enable our people to succeed. NASA now has the opportunity enable our people to succeed. succeed. succeed. succeed. succeed. succeed. succeed. succeed. succeed. succeed. succeed. NASA now has the opportunity opportunity opportunity opportunity opportunity opportunity opportunity opportunity opportunity opportunity opportunity 

to examine its organizational structure and redesign or create to examine examine examine examine examine examine examine examine examine examine examine its organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational structure structure structure structure structure structure structure structure structure structure structure and redesign redesign redesign redesign redesign redesign redesign redesign redesign redesign redesign or create 

new organizational elements that are inherently healthier and new organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational elements elements elements elements elements elements elements elements elements elements elements that are inherently inherently inherently inherently inherently inherently inherently inherently inherently inherently inherently healthier healthier healthier healthier healthier healthier healthier healthier healthier healthier healthier and 

succeed in creating the proper checks-and-balances and chains succeed succeed succeed succeed succeed succeed succeed succeed succeed succeed succeed in creating creating creating creating creating creating creating creating creating creating creating the proper checks-and-balances checks-and-balances checks-and-balances checks-and-balances checks-and-balances checks-and-balances checks-and-balances checks-and-balances checks-and-balances checks-and-balances checks-and-balances and chains 

of accountability to enable effective communication and deci- of accountability accountability accountability accountability accountability accountability accountability accountability accountability accountability accountability accountability to enable effective fective fective fective fective fective fective fective fective fective fective fective communication communication communication communication communication communication communication communication communication communication communication communication and decision-making.

Table 7. The Diaz Team developed one goal for Organizational Structure.

Organizational Structure – Diaz Team Goal

The Agency should complete its current NASA-wide assessment and establish independent technical authority.
1 6

Table 8. The Diaz Team developed one goal for Risk Management.

Risk Management – Diaz Team Goal

The Agency should identify a set of risk management processes and tools which can be applied across all programs which 

recognize the diversity with respect to risk tolerance.

1.8 RISK MANAGEMENT

CAIB Report Chapter 1, p25:

As the investigation continued, it revealed a NASA culture that had gradually begun to accept escalating risk, 

and a NASA safety program that was largely silent and ineffective.

NASA fails to account for program risk.

Agency-wide Themes

• NASA must establish a consistent set of risk assessment tools, applied in a uniform way, across 

all programs.

• NASA management must have a clear understanding of safety requirements and risks associated with key decisions.

• NASA must stop accepting increasing levels of 

risk without understanding the total program risk.

The public generally understands that space travel is not a risk- The public generally generally generally generally generally generally generally generally generally generally generally understands understands understands understands understands understands understands understands understands understands understands that space travel is not a riskfree undertaking. NASAʼs history includes many “fi rsts,” and free undertaking. undertaking. undertaking. undertaking. undertaking. undertaking. undertaking. undertaking. undertaking. undertaking. undertaking. undertaking. NASAʼs history history history history history history history history history history history history includes includes includes includes includes includes includes includes includes includes includes includes many “firsts,” and 

most of them have involved considerable risk. In the Human most of them have involved involved involved involved involved involved involved involved involved involved involved considerable considerable considerable considerable considerable considerable considerable considerable considerable considerable considerable risk. In the Human 

Space Flight Program, the risk has been to human life itself. Space Flight Program, Program, Program, Program, Program, Program, Program, Program, Program, Program, Program, the risk has been to human life itself. itself. itself. itself. itself. itself. itself. itself. itself. itself. itself. 

But even when no crewmembers are launched, NASA has the But even when no crewmembers crewmembers crewmembers crewmembers crewmembers crewmembers crewmembers crewmembers crewmembers crewmembers crewmembers are launched, launched, launched, launched, launched, launched, launched, launched, launched, launched, launched, NASA has the 

responsibility of ensuring that the publicʼs investment in the responsibility responsibility responsibility responsibility responsibility responsibility responsibility responsibility responsibility responsibility responsibility of ensuring ensuring ensuring ensuring ensuring ensuring ensuring ensuring ensuring ensuring ensuring that the publicʼ publicʼ publicʼ publicʼ publicʼ publicʼ publicʼ publicʼ publicʼ publicʼ publicʼs investment investment investment investment investment investment investment investment investment investment investment in the 

space program is a wise investment and that we are successful space program program program program program program program program program program program program is a wise investment investment investment investment investment investment investment investment investment investment investment investment and that we are successful successful successful successful successful successful successful successful successful successful successful successful 

in achieving our mission. This should not be forgotten when we in achieving achieving achieving achieving achieving achieving achieving achieving achieving achieving achieving our mission. mission. mission. mission. mission. mission. mission. mission. mission. mission. mission. This should not be forgotten when we 

consider risk management. 

NASAʼs vision and mission can only be achieved by accepting NASAʼs vision and mission mission mission mission mission mission mission mission mission mission mission mission can only be achieved achieved achieved achieved achieved achieved achieved achieved achieved achieved achieved achieved by accepting accepting accepting accepting accepting accepting accepting accepting accepting accepting accepting accepting 

risk. Acceptance means understanding the risks, as well as man- risk. Acceptance Acceptance Acceptance Acceptance Acceptance Acceptance Acceptance Acceptance Acceptance Acceptance Acceptance means understanding understanding understanding understanding understanding understanding understanding understanding understanding understanding understanding the risks, as well as managing and documenting them. The CAIB Report observed: aging and documenting them. The CAIB Report observed:

Quantitative safety assessments in the Navy submarine Quantitative safety assessments in the Navy submarine

program are deterministic rather than probabilistic. NASA program are deterministic rather than probabilistic. NASA

does not have a quantitative, program-wide risk and safety does not have a quantitative, program-wide risk and safety

database to support future design capabilities and assist database to support future design capabilities and assist

risk assessment teams. (CAIB Report, Chapter 7, p. 183) risk assessment teams. (CAIB Report, Chapter 7, p. 183)

A fundamental tenet of NASA programs, displayed throughout A fundamental fundamental fundamental fundamental fundamental fundamental fundamental fundamental fundamental fundamental fundamental tenet of NASA programs, programs, programs, programs, programs, programs, programs, programs, programs, programs, programs, displayed displayed displayed displayed displayed displayed displayed displayed displayed displayed displayed throughout throughout throughout throughout throughout throughout throughout throughout throughout throughout throughout 

all fi eld Centers and contractor facilities, is safety and mission all field Centers Centers Centers Centers Centers Centers Centers Centers Centers Centers Centers and contractor contractor contractor contractor contractor contractor contractor contractor contractor contractor contractor facilities, facilities, facilities, facilities, facilities, facilities, facilities, facilities, facilities, facilities, facilities, is safety and mission mission mission mission mission mission mission mission mission mission mission 

assurance. Yet, for all its decades of efforts managing inherently assurance. assurance. assurance. assurance. assurance. assurance. assurance. assurance. assurance. assurance. assurance. assurance. Yet, for all its decades decades decades decades decades decades decades decades decades decades decades decades of efforts managing managing managing managing managing managing managing managing managing managing managing managing inherently inherently inherently inherently inherently inherently inherently inherently inherently inherently inherently inherently 

risky spacefl ight activities, NASAʼs organization and risk man- risky spacefl spaceight activities, activities, activities, activities, activities, activities, activities, activities, activities, activities, activities, NASAʼs organization ganization ganization ganization ganization ganization ganization ganization ganization ganization ganization and risk management processes failed in the losses of agement agement agement agement agement agement agement agement processes processes processes processes processes processes processes processes failed in the losses of Challenger Challenger and Columbia. Ultimately, the CAIB found a Shuttle Program history . Ultimately Ultimately Ultimately Ultimately Ultimately Ultimately Ultimately Ultimately Ultimately Ultimately, the CAIB found a Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Program Program Program Program Program Program Program Program Program Program history history history history history history history history history history 

of increasing risk. Where did the increasing risks come from? of increasing increasing increasing increasing increasing increasing increasing increasing increasing increasing increasing increasing risk. Where did the increasing increasing increasing increasing increasing increasing increasing increasing increasing increasing increasing increasing risks come from? 

According to the CAIB, the answer lies in the traits of the Shuttle According According According According According According According According According According According to the CAIB, the answer lies in the traits of the Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle 

Programʼs organizational culture that “accepted escalating risk” Programʼ Programʼ Programʼ Programʼ Programʼ Programʼ Programʼ Programʼ Programʼ Programʼ Programʼs organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational culture culture culture culture culture culture culture culture culture culture culture that “accepted “accepted “accepted “accepted “accepted “accepted “accepted “accepted “accepted “accepted “accepted escalating escalating escalating escalating escalating escalating escalating escalating escalating escalating escalating risk” 

and a “safety program that was largely silent and ineffective.” and a “safety “safety “safety “safety “safety “safety “safety “safety “safety “safety program program program program program program program program program program that was largely silent and ineffective.” fective.” fective.” fective.” fective.” fective.” fective.” fective.” fective.” fective.” 

The CAIB recommendations and fi ndings in the risk manage- The CAIB recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations and findings in the risk manage- manage- manage- manage- manage- manage- manage- manage- manage- manage- management area and the Safety and Mission Success Week responses ment area and the Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Success Success Success Success Success Success Success Success Success Success Week responses responses responses responses responses responses responses responses responses responses 

from the workforce provide a clear picture of the issues and chal- from the workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce provide provide provide provide provide provide provide provide provide provide provide a clear picture picture picture picture picture picture picture picture picture picture picture of the issues and challenges NASA faces in managing future risks. lenges NASA faces in managing future risks.

The incremental and insidious growth of risk in programs is a The incremental incremental incremental incremental incremental incremental incremental incremental incremental incremental and insidious insidious insidious insidious insidious insidious insidious insidious insidious insidious growth of risk in programs programs programs programs programs programs programs programs programs programs is a 

key theme within the CAIB fi ndings. Another theme in the CAIB key theme within the CAIB findings. ndings. ndings. ndings. ndings. ndings. ndings. ndings. ndings. ndings. ndings. Another Another Another Another Another Another Another Another Another Another Another theme in the CAIB 

Report is the necessity to set uniform standards and assessment Report is the necessity necessity necessity necessity necessity necessity necessity necessity necessity necessity to set uniform uniform uniform uniform uniform uniform uniform uniform uniform uniform standards standards standards standards standards standards standards standards standards standards and assessment assessment assessment assessment assessment assessment assessment assessment assessment assessment 

methodologies across all programs. Another major theme em- methodologies methodologies methodologies methodologies methodologies methodologies methodologies methodologies methodologies methodologies across all programs. programs. programs. programs. programs. programs. programs. programs. programs. programs. Another Another Another Another Another Another Another Another Another Another major theme embodied in the CAIB Report was managementʼs understanding of bodied in the CAIB Report was managementʼ managementʼ managementʼ managementʼ managementʼ managementʼ managementʼ managementʼ managementʼ managementʼ managementʼs understanding understanding understanding understanding understanding understanding understanding understanding understanding understanding understanding of 

the risks associated with key decisions. Systematically, resource the risks associated associated associated associated associated associated associated associated associated associated with key decisions. decisions. decisions. decisions. decisions. decisions. decisions. decisions. decisions. decisions. Systematically Systematically Systematically Systematically Systematically Systematically Systematically Systematically Systematically Systematically, resource resource resource resource resource resource resource resource resource resource 

constraints and schedule pressures clouded management deci- constraints constraints constraints constraints constraints constraints constraints constraints constraints constraints constraints and schedule schedule schedule schedule schedule schedule schedule schedule schedule schedule schedule pressures pressures pressures pressures pressures pressures pressures pressures pressures pressures pressures clouded clouded clouded clouded clouded clouded clouded clouded clouded clouded clouded management management management management management management management management management management management decisions. As for resources, the Board noted that adequate resources sions. As for resources, resources, resources, resources, resources, resources, resources, resources, resources, resources, the Board noted that adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate resources resources resources resources resources resources resources resources resources resources 

and independent assessments are critical to risk management and and independent independent independent independent independent independent independent independent independent independent independent assessments assessments assessments assessments assessments assessments assessments assessments assessments assessments assessments are critical critical critical critical critical critical critical critical critical critical critical to risk management management management management management management management management management management management and 

decision-making. Agency-wide, NASA can look at its programs decision-making. decision-making. decision-making. decision-making. decision-making. decision-making. decision-making. decision-making. decision-making. decision-making. Agency-wide, Agency-wide, Agency-wide, Agency-wide, Agency-wide, Agency-wide, Agency-wide, Agency-wide, Agency-wide, Agency-wide, NASA can look at its programs programs programs programs programs programs programs programs programs programs 

to determine whether independent organizations are properly to determine determine determine determine determine determine determine determine determine determine whether whether whether whether whether whether whether whether whether whether independent independent independent independent independent independent independent independent independent independent organizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations are properly properly properly properly properly properly properly properly properly properly 

resourced and suffi ciently independent. resourced and sufficiently independent.

The feedback from Safety and Mission Success Week reinforced The feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback from Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Success Success Success Success Success Success Success Success Success Success Success Week reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced 

the Diaz Team assessment: the Diaz Team assessment:

» Missions and programs are being driven by budget and 

schedule, and a ʻfaster, better, cheaperʼ philosophy. schedule, and a ʻfaster schedule, and a ʻfaster schedule, and a ʻfaster schedule, and a ʻfaster schedule, and a ʻfaster schedule, and a ʻfaster schedule, and a ʻfaster schedule, and a ʻfaster schedule, and a ʻfaster, better , better , better , better , better , better , better , better , better, cheaper , cheaper , cheaper , cheaper , cheaper , cheaper , cheaper , cheaper , cheaperʼ philosophy philosophy philosophy philosophy philosophy philosophy philosophy philosophy philosophy. 

Cost and schedule pressures have surpassed technical 

quality as the drivers for decision making for projects.

» As in the CAIB Report, Center employees expressed 

concern over our “can do” attitude, which “goes too 

far and becomes arrogance, leaving us blind to external 

information.” It tempts us to accept greater risk than 

may be reasonable or responsible.

Agency-wide, a consistent set of risk assessment tools, applied in Agency-wide, Agency-wide, Agency-wide, Agency-wide, Agency-wide, Agency-wide, Agency-wide, Agency-wide, Agency-wide, Agency-wide, Agency-wide, a consistent consistent consistent consistent consistent consistent consistent consistent consistent consistent consistent set of risk assessment assessment assessment assessment assessment assessment assessment assessment assessment assessment assessment tools, applied applied applied applied applied applied applied applied applied applied applied in 

a uniform way, will help assure mission success. When applied a uniform uniform uniform uniform uniform uniform uniform uniform uniform uniform way, will help assure mission mission mission mission mission mission mission mission mission mission success. success. success. success. success. success. success. success. success. success. When applied applied applied applied applied applied applied applied applied applied 

throughout NASA, all programs would be served by having the throughout throughout throughout throughout throughout throughout throughout throughout throughout throughout NASA, all programs programs programs programs programs programs programs programs programs programs would be served by having the 

best information available by which to make decisions that could best information information information information information information information information information information information available available available available available available available available available available available by which to make decisions decisions decisions decisions decisions decisions decisions decisions decisions decisions decisions that could 

impact safety and mission success.

In addition to the actions in the Diaz Team Matrix that address In addition addition addition addition addition addition addition addition addition addition to the actions actions actions actions actions actions actions actions actions actions in the Diaz Team Matrix that address address address address address address address address address address 

each R-O-F, the Diaz Team has one goal addressing the Risk each R-O-F, the Diaz Team has one goal addressing addressing addressing addressing addressing addressing addressing addressing addressing addressing addressing the Risk 

Management category, as shown in Table 8. Management category, as shown in Table 8.
1 7

1.9 SUMMARY

In summary, the CAIB Report includes signifi cant technical and In summary summary summary summary summary summary summary summary summary summary summary summary, the CAIB Report includes includes includes includes includes includes includes includes includes includes includes includes signifi signicant technical technical technical technical technical technical technical technical technical technical technical technical and 

non-technical R-O-Fs, which NASA leaders must adhere to in non-technical non-technical non-technical non-technical non-technical non-technical non-technical non-technical non-technical non-technical non-technical R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, which NASA leaders leaders leaders leaders leaders leaders leaders leaders leaders leaders leaders must adhere to in 

order to help the Agency move forward to meet the challenges order to help the Agency move forward forward forward forward forward forward forward forward forward forward forward forward to meet the challenges challenges challenges challenges challenges challenges challenges challenges challenges challenges challenges challenges 

of the future. The Diaz Team realizes that, in some respects, the of the future. future. future. future. future. future. future. future. future. future. future. The Diaz Team realizes realizes realizes realizes realizes realizes realizes realizes realizes realizes realizes that, in some respects, respects, respects, respects, respects, respects, respects, respects, respects, respects, respects, the 

most challenging changes will be those which pertain to culture, most challenging challenging challenging challenging challenging challenging challenging challenging challenging challenging challenging challenging changes changes changes changes changes changes changes changes changes changes changes changes will be those which pertain pertain pertain pertain pertain pertain pertain pertain pertain pertain pertain pertain to culture, culture, culture, culture, culture, culture, culture, culture, culture, culture, culture, culture, 

or those which are the non-technical R-O-Fs noted in the CAIB or those which are the non-technical non-technical non-technical non-technical non-technical non-technical non-technical non-technical non-technical non-technical non-technical R-O-Fs noted in the CAIB 

Report. 

All of this can be traced back to the culture of the organization. All of this can be traced back to the culture culture culture culture culture culture culture culture culture culture culture of the organization. ganization. ganization. ganization. ganization. ganization. ganization. ganization. ganization. ganization. ganization. 

The CAIB Report discussed organizational culture this way: The CAIB Report discussed organizational culture this way:

Organizational culture refers to the basic values, norms, Organizational Organizational Organizational Organizational Organizational Organizational Organizational Organizational Organizational Organizational culture culture culture culture culture culture culture culture culture culture refers to the basic values, values, values, values, values, values, values, values, values, values, norms, 

beliefs, and practices that characterize the functioning of beliefs, beliefs, beliefs, beliefs, beliefs, beliefs, beliefs, beliefs, beliefs, and practices practices practices practices practices practices practices practices practices that characterize characterize characterize characterize characterize characterize characterize characterize characterize the functioning functioning functioning functioning functioning functioning functioning functioning functioning of 

a particular institution. At the most basic level, organiza- a particular particular particular particular particular particular particular particular particular particular institution. institution. institution. institution. institution. institution. institution. institution. institution. institution. At the most basic level, organiza- organiza- organiza- organiza- organiza- organiza- organiza- organiza- organiza- organizational culture defi nes the assumptions that employees tional culture culture culture culture culture culture culture culture culture defines the assumptions assumptions assumptions assumptions assumptions assumptions assumptions assumptions assumptions that employees employees employees employees employees employees employees employees employees 

make as they carry out their work; it defi nes “the way we make as they carry out their work; it defines “the way we 

do things here.” An organization’s culture is a powerful do things here.” An organization’ organization’ organization’ organization’ organization’ organization’ organization’ organization’ organization’ organization’s culture culture culture culture culture culture culture culture culture culture is a powerful powerful powerful powerful powerful powerful powerful powerful powerful powerful 

force that persists through reorganizations and the depar- force that persists persists persists persists persists persists persists persists persists through through through through through through through through through reorganizations reorganizations reorganizations reorganizations reorganizations reorganizations reorganizations reorganizations reorganizations and the departure of key personnel. (CAIB Report, Chapter 5, p. 101)

The Team knows the organizational changes recommended in the The Team knows the organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational changes changes changes changes changes changes changes changes changes changes changes changes recommended recommended recommended recommended recommended recommended recommended recommended recommended recommended recommended recommended in the 

CAIB Report will require sustained planning and implementa- CAIB Report will require require require require require require require require require require require sustained sustained sustained sustained sustained sustained sustained sustained sustained sustained sustained planning planning planning planning planning planning planning planning planning planning planning and implementa- implementa- implementa- implementa- implementa- implementa- implementa- implementa- implementa- implementa- implementation over time to achieve the desired future the CAIB and NASA tion over time to achieve achieve achieve achieve achieve achieve achieve achieve achieve achieve achieve the desired desired desired desired desired desired desired desired desired desired desired future the CAIB and NASA

foresee. When making cultural change, large organizations such foresee. foresee. foresee. foresee. foresee. foresee. foresee. foresee. foresee. foresee. foresee. When making cultural cultural cultural cultural cultural cultural cultural cultural cultural cultural cultural change, change, change, change, change, change, change, change, change, change, change, large organizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations such 

as NASA need to assure that, throughout the change process, the as NASA need to assure that, throughout throughout throughout throughout throughout throughout throughout throughout throughout throughout throughout the change process, process, process, process, process, process, process, process, process, process, process, the 

organizationʼs core values are both relied on and sustained. The organizationʼ ganizationʼ ganizationʼ ganizationʼ ganizationʼ ganizationʼ ganizationʼ ganizationʼ ganizationʼ ganizationʼ ganizationʼ ganizationʼs core values are both relied on and sustained. sustained. sustained. sustained. sustained. sustained. sustained. sustained. sustained. sustained. sustained. sustained. The 

Team believes these core values will help the Agencyʼs leaders Team believes believes believes believes believes believes believes believes believes believes believes these core values will help the Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼs leaders leaders leaders leaders leaders leaders leaders leaders leaders leaders leaders 

take on the serious challenges ahead, which should yield im- take on the serious serious serious serious serious serious serious serious serious serious serious serious challenges challenges challenges challenges challenges challenges challenges challenges challenges challenges challenges challenges ahead, which should yield improved safety, performance excellence, and mission success. proved safety, performance excellence, and mission success. 

The proposed actions in the Diaz Team Report are based on cul- The proposed proposed proposed proposed proposed proposed proposed proposed proposed proposed proposed actions actions actions actions actions actions actions actions actions actions actions in the Diaz Team Report are based on culture-related issues identifi ed by NASA leadership and the work- ture-related ture-related ture-related ture-related ture-related ture-related ture-related ture-related ture-related ture-related ture-related issues identifi identifi identifi identifi identifi identifi identifi identifi identifi identifi identified by NASA leadership leadership leadership leadership leadership leadership leadership leadership leadership leadership leadership and the workforce in the areas of: leadership, learning, communication, pro- force in the areas of: leadership, leadership, leadership, leadership, leadership, leadership, leadership, leadership, leadership, leadership, leadership, leadership, learning, learning, learning, learning, learning, learning, learning, learning, learning, learning, learning, learning, communication, communication, communication, communication, communication, communication, communication, communication, communication, communication, communication, communication, processes and rules, technical capabilities, organizational structure, cesses and rules, technical technical technical technical technical technical technical technical technical technical technical capabilities, capabilities, capabilities, capabilities, capabilities, capabilities, capabilities, capabilities, capabilities, capabilities, capabilities, organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational structure, structure, structure, structure, structure, structure, structure, structure, structure, structure, structure, 

and risk management. The Team believes a systematic approach and risk management. management. management. management. management. management. management. management. management. management. management. management. The Team believes believes believes believes believes believes believes believes believes believes believes believes a systematic systematic systematic systematic systematic systematic systematic systematic systematic systematic systematic systematic approach approach approach approach approach approach approach approach approach approach approach approach 

to cultural change at this critical juncture of the Agencyʼs history to cultural cultural cultural cultural cultural cultural cultural cultural cultural cultural cultural change at this critical critical critical critical critical critical critical critical critical critical critical juncture juncture juncture juncture juncture juncture juncture juncture juncture juncture juncture of the Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼs history history history history history history history history history history history 

will yield a NASA culture that is signifi cantly more responsive will yield a NASA culture culture culture culture culture culture culture culture culture culture culture culture that is signifi signicantly more responsive responsive responsive responsive responsive responsive responsive responsive responsive responsive responsive responsive 

and prepared for the promising opportunities of the American and prepared prepared prepared prepared prepared prepared prepared prepared prepared prepared prepared for the promising promising promising promising promising promising promising promising promising promising promising opportunities opportunities opportunities opportunities opportunities opportunities opportunities opportunities opportunities opportunities opportunities of the American American American American American American American American American American American 

space programʼs future. space programʼs future.

NASA stands at a crossroads. One path is a continuation of the NASA stands at a crossroads. crossroads. crossroads. crossroads. crossroads. crossroads. crossroads. crossroads. crossroads. crossroads. crossroads. One path is a continuation continuation continuation continuation continuation continuation continuation continuation continuation continuation continuation of the 

course that allowed the course that allowed the Challenger Challenger and Columbia accidents to accidents to 

occur. The new path of change may be diffi cult, particularly at occur. The new path of change may be difficult, particularly particularly particularly particularly particularly particularly particularly particularly particularly particularly particularly at 

the start, and sometimes the goal is not always in sight. But the the start, and sometimes sometimes sometimes sometimes sometimes sometimes sometimes sometimes sometimes sometimes sometimes sometimes the goal is not always in sight. But the 

rewards for walking this path are far greater than those the old rewards rewards rewards rewards rewards rewards rewards rewards rewards rewards rewards for walking walking walking walking walking walking walking walking walking walking walking this path are far greater greater greater greater greater greater greater greater greater greater greater than those the old 

path could ever offer us. path could ever offer us. 

For NASA to embark on the new pathway, some fundamental For NASA to embark on the new pathway pathway pathway pathway pathway pathway pathway pathway pathway pathway pathway, some fundamental fundamental fundamental fundamental fundamental fundamental fundamental fundamental fundamental fundamental fundamental 

reforms must be instituted. These are encompassed by the 40 reforms reforms reforms reforms reforms reforms reforms reforms reforms reforms reforms must be instituted. instituted. instituted. instituted. instituted. instituted. instituted. instituted. instituted. instituted. instituted. These are encompassed encompassed encompassed encompassed encompassed encompassed encompassed encompassed encompassed encompassed encompassed by the 40 

Diaz Team actions and seven goals identifi ed in the Report. The Diaz Team actions actions actions actions actions actions actions actions actions actions actions and seven goals identifi identifi identifi identifi identifi identifi identifi identifi identifi identifi identified in the Report. Report. Report. Report. Report. Report. Report. Report. Report. Report. Report. The 

essence of these can be captured in three overarching reforms:

• NASA must assure that appropriate checks and bal- NASA must assure that appropriate checks and balances are in place to develop and operate its missions 

safely, and must undertake the organizational changes safely, and must undertake the organizational changes 

necessary to make this happen. The organizational necessary to make this happen. The organizational 

structure should help clarify roles and responsibilities 

of individual employees, work groups and leadership. 

Every member of the workforce must know his or her 

position in the organization and all must know their position in the organization and all must know their 

authority, responsibility and accountability for assur- authority, responsibility and accountability for assuring mission success. The entire workforce must also be ing mission success. The entire workforce must also be 

aware of and understand the rules.

• NASA must enhance communications at all levels NASA must enhance communications at all levels 

with a focus on fostering diversity of viewpoints and 

eliminating fear of retribution. A communications cul- eliminating fear of retribution. A communications culture must be established with formal communications 

procedures to ensure effective communications fl ow up procedures to ensure effective communications flow up 

and down the chain of command and across organiza- and down the chain of command and across organizational lines. Communications channels should be suffi ciently fl exible to support, encourage, and objectively ficiently flexible to support, encourage, and objectively 

evaluate all viewpoints, ensuring sound decision-making practices.

• NASA must focus on the ways it is managing risk. NASA must focus on the ways it is managing risk. 

Safety, mission success and program performance Safety, mission success and program performance 

must not be the product of schedule and budget pressures alone. Technological and workforce factors must sures alone. Technological and workforce factors must 

be considered in program planning and decision-making as well. A critical role of leadership is to ensure ing as well. A critical role of leadership is to ensure 

there is an appropriate balance between requirements, 

resources and risk. NASA must assure that the work- resources and risk. NASA must assure that the workforce has the appropriate processes, tools and technical 

capabilities to accomplish this.

1.10 NEXT STEPS

It should be noted the NASA Administrator asked the Team in It should be noted the NASA Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator asked the Team in 

its charter to identify broadly applicable R-O-Fs in the CAIB its charter charter charter charter charter charter charter charter charter charter charter to identify identify identify identify identify identify identify identify identify identify identify broadly broadly broadly broadly broadly broadly broadly broadly broadly broadly broadly applicable applicable applicable applicable applicable applicable applicable applicable applicable applicable applicable R-O-Fs in the CAIB 

Report, recommend actions to address those R-O-Fs, and submit Report, Report, Report, Report, Report, Report, Report, Report, Report, Report, Report, recommend recommend recommend recommend recommend recommend recommend recommend recommend recommend recommend actions actions actions actions actions actions actions actions actions actions actions to address address address address address address address address address address address those R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, and submit 

a Report documenting its conclusions and recommendations to a Report documenting documenting documenting documenting documenting documenting documenting documenting documenting documenting documenting documenting its conclusions conclusions conclusions conclusions conclusions conclusions conclusions conclusions conclusions conclusions conclusions conclusions and recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations to 

the NASA Deputy Administrator. The responsibility for prepar- the NASA Deputy Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator. The responsibility responsibility responsibility responsibility responsibility responsibility responsibility responsibility responsibility responsibility responsibility for preparing implementation plans to accomplish the 40 “specifi c actions” ing implementation implementation implementation implementation implementation implementation implementation implementation implementation implementation implementation implementation plans to accomplish accomplish accomplish accomplish accomplish accomplish accomplish accomplish accomplish accomplish accomplish accomplish the 40 “specifi “specifi “specifi “specifi “specifi “specifi “specifi “specifi “specifi “specifi “specifi “specific actions” actions” actions” actions” actions” actions” actions” actions” actions” actions” actions” actions” 

in the Diaz Team Matrix was given to the appropriate NASA in the Diaz Team Matrix was given to the appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate NASA

Headquarters organizations. The responsibility for accomplish- Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters organizations. ganizations. ganizations. ganizations. ganizations. ganizations. ganizations. ganizations. ganizations. ganizations. ganizations. ganizations. The responsibility responsibility responsibility responsibility responsibility responsibility responsibility responsibility responsibility responsibility responsibility responsibility for accomplish- accomplish- accomplish- accomplish- accomplish- accomplish- accomplish- accomplish- accomplish- accomplish- accomplish- accomplishing the seven “Diaz Team Goals” is not identifi ed in the Report. ing the seven “Diaz Team Goals” is not identifi identifi identifi identifi identifi identifi identifi identifi identifi identifi identified in the Report. Report. Report. Report. Report. Report. Report. Report. Report. Report. Report. 

However, it is anticipated that the NASA Deputy Administrator However However However However However However However However However However However However, it is anticipated anticipated anticipated anticipated anticipated anticipated anticipated anticipated anticipated anticipated anticipated anticipated that the NASA Deputy Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator 

will provide direction to the development of all implementation will provide provide provide provide provide provide provide provide provide provide provide direction direction direction direction direction direction direction direction direction direction direction to the development development development development development development development development development development development of all implementation implementation implementation implementation implementation implementation implementation implementation implementation implementation implementation 

plans. It is recommended that all the implementation plans pre- plans. It is recommended recommended recommended recommended recommended recommended recommended recommended recommended recommended recommended that all the implementation implementation implementation implementation implementation implementation implementation implementation implementation implementation implementation plans prepared in response to the CAIB Report (i.e. RTF, CTF, Next Gen- pared in response response response response response response response response response response response response to the CAIB Report (i.e. RTF, CTF, Next Generation Vehicle, Diaz Team and Aircraft Operations) be placed eration eration eration eration eration eration eration eration eration eration eration Vehicle, ehicle, ehicle, ehicle, ehicle, ehicle, ehicle, ehicle, ehicle, ehicle, ehicle, Diaz Team and Aircraft Aircraft Aircraft Aircraft Aircraft Aircraft Aircraft Aircraft Aircraft Aircraft Aircraft Operations) Operations) Operations) Operations) Operations) Operations) Operations) Operations) Operations) Operations) Operations) be placed 

under confi guration control, and any intent to establish other under configuration guration guration guration guration guration guration guration guration guration guration guration control, control, control, control, control, control, control, control, control, control, control, control, and any intent to establish establish establish establish establish establish establish establish establish establish establish establish other 

implementation plans be subject to approval by the Deputy Ad- implementation implementation implementation implementation implementation implementation implementation implementation implementation implementation implementation plans be subject subject subject subject subject subject subject subject subject subject subject to approval approval approval approval approval approval approval approval approval approval approval by the Deputy Administrator. It is further anticipated that NASA will implement ministrator ministrator ministrator ministrator ministrator ministrator ministrator ministrator ministrator ministrator ministrator ministrator. It is further further further further further further further further further further further further anticipated anticipated anticipated anticipated anticipated anticipated anticipated anticipated anticipated anticipated anticipated anticipated that NASA will implement implement implement implement implement implement implement implement implement implement implement implement 

the appropriate systems to coordinate and track the progress of the appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate systems systems systems systems systems systems systems systems systems systems systems to coordinate coordinate coordinate coordinate coordinate coordinate coordinate coordinate coordinate coordinate coordinate and track the progress progress progress progress progress progress progress progress progress progress progress of 

their implementation.

The Diaz Team suggests that NASA should periodically review The Diaz Team suggests suggests suggests suggests suggests suggests suggests suggests suggests suggests suggests that NASA should periodically periodically periodically periodically periodically periodically periodically periodically periodically periodically periodically review 

and measure the progress of all implementation activities in and measure measure measure measure measure measure measure measure measure measure measure measure the progress progress progress progress progress progress progress progress progress progress progress progress of all implementation implementation implementation implementation implementation implementation implementation implementation implementation implementation implementation implementation activities activities activities activities activities activities activities activities activities activities activities activities in 

response to the CAIB Report. It is suggested that this assess- response response response response response response response response response response response to the CAIB Report. Report. Report. Report. Report. Report. Report. Report. Report. Report. Report. It is suggested suggested suggested suggested suggested suggested suggested suggested suggested suggested suggested that this assess- assess- assess- assess- assess- assess- assess- assess- assess- assess- assessment be conducted six months after the release of the Diaz Team ment be conducted conducted conducted conducted conducted conducted conducted conducted conducted conducted conducted conducted six months after the release release release release release release release release release release release release of the Diaz Team 

Report, and annually thereafter. The Diaz Team, or some subset Report, Report, Report, Report, Report, Report, Report, Report, Report, Report, Report, and annually annually annually annually annually annually annually annually annually annually annually thereafter thereafter thereafter thereafter thereafter thereafter thereafter thereafter thereafter thereafter thereafter. The Diaz Team, or some subset 

thereof, could perform this assessment. 
1 8

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1 9

This Report documents the activities of the Diaz Team. The This Report documents documents documents documents documents documents documents documents documents documents documents documents the activities activities activities activities activities activities activities activities activities activities activities activities of the Diaz Team. The 

Team was assigned by NASA Administrator Sean OʼKeefe with Team was assigned assigned assigned assigned assigned assigned assigned assigned assigned assigned assigned by NASA Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Sean OʼKeefe OʼKeefe OʼKeefe OʼKeefe OʼKeefe OʼKeefe OʼKeefe OʼKeefe OʼKeefe OʼKeefe OʼKeefe with 

the responsibility of exploring the Agency-wide applicability of the responsibility responsibility responsibility responsibility responsibility responsibility responsibility responsibility responsibility responsibility responsibility responsibility of exploring exploring exploring exploring exploring exploring exploring exploring exploring exploring exploring exploring the Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability of 

the Columbia Accident Investigation Board Report. The Diaz the Columbia Columbia Columbia Columbia Columbia Columbia Columbia Columbia Columbia Columbia Columbia Accident Accident Accident Accident Accident Accident Accident Accident Accident Accident Accident Investigation Investigation Investigation Investigation Investigation Investigation Investigation Investigation Investigation Investigation Investigation Board Report. Report. Report. Report. Report. Report. Report. Report. Report. Report. Report. The Diaz 

Team Report documents the discussions, conclusions, and goals Team Report documents documents documents documents documents documents documents documents documents documents documents documents the discussions, discussions, discussions, discussions, discussions, discussions, discussions, discussions, discussions, discussions, discussions, discussions, conclusions, conclusions, conclusions, conclusions, conclusions, conclusions, conclusions, conclusions, conclusions, conclusions, conclusions, conclusions, and goals 

of the Diaz Team. of the Diaz Team.

2.1 BACKGROUND ACKGROUND

Over the past eleven months, NASA has initiated a number of Over the past eleven months, months, months, months, months, months, months, months, months, months, months, months, NASA has initiated initiated initiated initiated initiated initiated initiated initiated initiated initiated initiated initiated a number of 

activities to investigate and understand the circumstances that activities activities activities activities activities activities activities activities activities activities activities to investigate investigate investigate investigate investigate investigate investigate investigate investigate investigate investigate and understand understand understand understand understand understand understand understand understand understand understand the circumstances circumstances circumstances circumstances circumstances circumstances circumstances circumstances circumstances circumstances circumstances that 

led to the loss of the Shuttle led to the loss of the Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Columbia and her crew. The NASA and her crew. The NASA

Administrator convened the CAIB on the day of the accident. Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator convened convened convened convened convened convened convened convened convened convened convened the CAIB on the day of the accident. accident. accident. accident. accident. accident. accident. accident. accident. accident. accident. 

This Board spent the next seven months doing a thorough in- This Board spent the next seven months doing a thorough thorough thorough thorough thorough thorough thorough thorough thorough thorough thorough thorough investigation of the accident, identifying not only the technical vestigation vestigation vestigation vestigation vestigation vestigation vestigation vestigation vestigation vestigation vestigation of the accident, accident, accident, accident, accident, accident, accident, accident, accident, accident, accident, identifying identifying identifying identifying identifying identifying identifying identifying identifying identifying identifying not only the technical technical technical technical technical technical technical technical technical technical technical 

reasons for the accident but also the underlying organizational reasons reasons reasons reasons reasons reasons reasons reasons reasons reasons reasons for the accident accident accident accident accident accident accident accident accident accident accident but also the underlying underlying underlying underlying underlying underlying underlying underlying underlying underlying underlying organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational 

reasons. The Board documented their R-O-Fs in a Report that reasons. reasons. reasons. reasons. reasons. reasons. reasons. reasons. reasons. reasons. reasons. reasons. The Board documented documented documented documented documented documented documented documented documented documented documented documented their R-O-Fs in a Report that 

was distributed in August 2003. The NASA Administrator then was distributed distributed distributed distributed distributed distributed distributed distributed distributed distributed distributed in August 2003. The NASA Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator then 

directed a number of teams to review the Report and determine directed directed directed directed directed directed directed directed directed directed directed directed a number of teams to review the Report and determine determine determine determine determine determine determine determine determine determine determine determine 

what actions the Agency should take to address the R-O-Fs in the what actions actions actions actions actions actions actions actions actions actions actions the Agency should take to address address address address address address address address address address address the R-O-Fs in the 

Report. The Return To Flight (RTF) Team began immediately to Report. Report. Report. Report. Report. Report. Report. Report. Report. Report. Report. Report. The Return To Flight (RTF) Team began immediately immediately immediately immediately immediately immediately immediately immediately immediately immediately immediately immediately to 

address the technical reasons for the accident and prepared an address address address address address address address address address address address the technical technical technical technical technical technical technical technical technical technical technical reasons reasons reasons reasons reasons reasons reasons reasons reasons reasons reasons for the accident accident accident accident accident accident accident accident accident accident accident and prepared prepared prepared prepared prepared prepared prepared prepared prepared prepared prepared an 

implementation plan in response to the technical recommenda- implementation implementation implementation implementation implementation implementation implementation implementation implementation implementation implementation plan in response response response response response response response response response response response to the technical technical technical technical technical technical technical technical technical technical technical recommenda- recommenda- recommenda- recommenda- recommenda- recommenda- recommenda- recommenda- recommenda- recommenda- recommendations in the Report. The NASA Administrator also established tions in the Report. Report. Report. Report. Report. Report. Report. Report. Report. Report. Report. The NASA Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator also established established established established established established established established established established established 

the Continuing Flight Team (CFT) to review the Report from the the Continuing Continuing Continuing Continuing Continuing Continuing Continuing Continuing Continuing Continuing Continuing Flight Team (CFT) to review the Report from the 

standpoint of its implications for the International Space Station standpoint standpoint standpoint standpoint standpoint standpoint standpoint standpoint standpoint standpoint standpoint standpoint of its implications implications implications implications implications implications implications implications implications implications implications implications for the International International International International International International International International International International International International Space Station Station Station Station Station Station Station Station Station Station Station Station 

(ISS). This team prepared an implementation plan to respond to (ISS). This team prepared prepared prepared prepared prepared prepared prepared prepared prepared prepared prepared an implementation implementation implementation implementation implementation implementation implementation implementation implementation implementation implementation plan to respond respond respond respond respond respond respond respond respond respond respond to 

the technical recommendations in the Report that had direct rela- the technical technical technical technical technical technical technical technical technical technical technical technical recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations in the Report that had direct relationship with the ISS.

Throughout the investigation, the Board focused on the physical Throughout Throughout Throughout Throughout Throughout Throughout Throughout Throughout Throughout Throughout Throughout the investigation, investigation, investigation, investigation, investigation, investigation, investigation, investigation, investigation, investigation, investigation, the Board focused focused focused focused focused focused focused focused focused focused focused on the physical physical physical physical physical physical physical physical physical physical physical 

causes of the accident but they realized that there were organi- causes of the accident accident accident accident accident accident accident accident accident accident accident but they realized realized realized realized realized realized realized realized realized realized realized that there were organizational causes as well. While the CAIB Report and subsequent zational zational zational zational zational zational zational zational zational zational zational zational causes as well. While the CAIB Report and subsequent subsequent subsequent subsequent subsequent subsequent subsequent subsequent subsequent subsequent subsequent subsequent 

recommendations focused on the former, the latter was also recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations focused focused focused focused focused focused focused focused focused focused focused on the former, the latter was also 

discussed, most specifi cally in Chapter 7, in the Organizational discussed, discussed, discussed, discussed, discussed, discussed, discussed, discussed, discussed, discussed, discussed, discussed, most specifi specically in Chapter Chapter Chapter Chapter Chapter Chapter Chapter Chapter Chapter Chapter Chapter Chapter 7, in the Organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational 

Cause Statement. The RTF and CFT Teams focused primarily Cause Statement. Statement. Statement. Statement. Statement. Statement. Statement. Statement. Statement. Statement. Statement. The RTF and CFT Teams focused focused focused focused focused focused focused focused focused focused focused primarily primarily primarily primarily primarily primarily primarily primarily primarily primarily primarily 

on those actions that were necessary to fl y the shuttle again (or on those actions actions actions actions actions actions actions actions actions actions actions actions that were necessary necessary necessary necessary necessary necessary necessary necessary necessary necessary necessary necessary to fly the shuttle shuttle shuttle shuttle shuttle shuttle shuttle shuttle shuttle shuttle shuttle shuttle again (or 

continue fl ying the ISS). However, the NASA Administrator rec- continue continue continue continue continue continue continue continue continue continue continue flying the ISS). However However However However However However However However However However However, the NASAAdministrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator recognized there were underlying messages in the CAIB Report that ognized ognized ognized ognized ognized ognized ognized ognized ognized ognized ognized ognized there were underlying underlying underlying underlying underlying underlying underlying underlying underlying underlying underlying underlying messages messages messages messages messages messages messages messages messages messages messages messages in the CAIB Report that 

applied beyond the Human Space Flight Program. Therefore, in applied applied applied applied applied applied applied applied applied applied applied beyond the Human Space Flight Program. Program. Program. Program. Program. Program. Program. Program. Program. Program. Program. Therefore, Therefore, Therefore, Therefore, Therefore, Therefore, Therefore, Therefore, Therefore, Therefore, Therefore, in 

September 2003 he established a team to review the CAIB Re- September September September September September September September September September September September 2003 he established established established established established established established established established established established a team to review the CAIB Report and identify those R-O-Fs that might apply broadly across port and identify identify identify identify identify identify identify identify identify identify identify identify those R-O-Fs that might apply broadly broadly broadly broadly broadly broadly broadly broadly broadly broadly broadly broadly across 

the Agency. the Agency. 

2.2 THE TEAM AND ITS CHARTER

The NASA Administrator asked Al Diaz, Director, Goddard Space The NASAAdministrator askedAl Diaz, Director, Goddard Space

Flight Center, to lead the team, which has come to be known as Flight Center, to lead the team, which has come to be known as

“The Diaz Team.” The Diaz Team includes: Dr. Ghassem Asrar, “The Diaz Team.” The Diaz Team includes: Dr. Ghassem Asrar,

Associate Administrator for Earth Science, NASA Headquarters; Associate Administrator for Earth Science, NASA Headquarters;

Dr. Julian Earls, Director, Glenn Research Center; Mr. Scott Dr. Julian Earls, Director, Glenn Research Center; Mr. Scott

Hubbard, Director, Ames Research Center; Mr. Jim Kennedy, Di- Hubbard, Director, Ames Research Center; Mr. Jim Kennedy, Director, Kennedy Space Center; and, Ms. Vicki Novak, Assistant rector, Kennedy Space Center; and, Ms. Vicki Novak, Assistant

Administrator for Human Resources, NASA Headquarters. Administrator for Human Resources, NASA Headquarters.

The Diaz Teamʼs charter was to: The Diaz Teamʼs charter was to:

• Identify those R-O-Fs from the CAIB Report that 

might apply across the Agency. might apply across the Agency.

• Identify a set of actions and suggested leadership for 

those actions.

• Include the One NASA Team in all activities. Include the One NASA Team in all activities.

• Summarize results in a Report to the NASA Deputy Summarize results in a Report to the NASA Deputy 

Administrator. Administrator.

It was immediately evident to the Diaz Team that while there were It was immediately immediately immediately immediately immediately immediately immediately immediately immediately immediately immediately evident evident evident evident evident evident evident evident evident evident evident to the Diaz Team that while there were 

very few CAIB recommendations that specifi cally addressed the very few CAIB recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations that specifi specically addressed addressed addressed addressed addressed addressed addressed addressed addressed addressed addressed addressed the 

organizational causes of the accident, there were none-the-less organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational causes of the accident, accident, accident, accident, accident, accident, accident, accident, accident, accident, accident, there were none-the-less none-the-less none-the-less none-the-less none-the-less none-the-less none-the-less none-the-less none-the-less none-the-less none-the-less 

clear messages in the Report that addressed the underlying or- clear messages messages messages messages messages messages messages messages messages messages messages messages in the Report that addressed addressed addressed addressed addressed addressed addressed addressed addressed addressed addressed addressed the underlying underlying underlying underlying underlying underlying underlying underlying underlying underlying underlying underlying organizational culture throughout NASA that allowed the accident ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational culture culture culture culture culture culture culture culture culture culture culture throughout throughout throughout throughout throughout throughout throughout throughout throughout throughout throughout NASA that allowed allowed allowed allowed allowed allowed allowed allowed allowed allowed allowed the accident accident accident accident accident accident accident accident accident accident accident 

to happen. It should be noted that while the Team focused on the to happen. happen. happen. happen. happen. happen. happen. happen. happen. happen. happen. happen. It should be noted that while the Team focused focused focused focused focused focused focused focused focused focused focused focused on the 

organizational causes described in the CAIB Report which were organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational causes described described described described described described described described described described described in the CAIB Report which were 

related to NASAʼs culture, the Team did not do a broad, in-depth related related related related related related related related related related related related to NASAʼs culture, culture, culture, culture, culture, culture, culture, culture, culture, culture, culture, culture, the Team did not do a broad, in-depth in-depth in-depth in-depth in-depth in-depth in-depth in-depth in-depth in-depth in-depth in-depth 

assessment of the cultural changes needed to address the orga- assessment assessment assessment assessment assessment assessment assessment assessment assessment assessment assessment of the cultural cultural cultural cultural cultural cultural cultural cultural cultural cultural cultural changes changes changes changes changes changes changes changes changes changes changes needed to address address address address address address address address address address address the organizational causes. The Team focused specifi cally on the CAIB nizational nizational nizational nizational nizational nizational nizational nizational nizational nizational nizational causes. causes. causes. causes. causes. causes. causes. causes. causes. causes. causes. The Team focused focused focused focused focused focused focused focused focused focused focused specifi specically on the CAIB 

Report and those R-O-Fs that had broad Agency-wide applica- Report and those R-O-Fs that had broad Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide applica- applica- applica- applica- applica- applica- applica- applica- applica- applica- applica- application beyond the Human Space Flight Program. Admittedly, some tion beyond the Human Space Flight Program. Program. Program. Program. Program. Program. Program. Program. Program. Program. Program. Admittedly Admittedly Admittedly Admittedly Admittedly Admittedly Admittedly Admittedly Admittedly Admittedly Admittedly, some 

of the actions recommended by the Team are actions one would of the actions actions actions actions actions actions actions actions actions actions actions actions recommended recommended recommended recommended recommended recommended recommended recommended recommended recommended recommended recommended by the Team are actions actions actions actions actions actions actions actions actions actions actions actions one would 

expect to see an organization take if it were trying to change its expect to see an organization ganization ganization ganization ganization ganization ganization ganization ganization ganization ganization take if it were trying to change its 

culture, but the goals offered by the Team are intended as only a culture, culture, culture, culture, culture, culture, culture, culture, culture, culture, culture, culture, but the goals offered by the Team are intended intended intended intended intended intended intended intended intended intended intended intended as only a 

fi rst step in the process. first step in the process.

2.3 R-O-F C R-O-F CATEGORIES ATEGORIES

Rather than maintain all 85 R-O-Fs as a single large group, the Rather than maintain maintain maintain maintain maintain maintain maintain maintain maintain maintain maintain maintain all 85 R-O-Fs as a single large group, the 

Diaz Team found arranging and presenting them in categories Diaz Team found arranging arranging arranging arranging arranging arranging arranging arranging arranging arranging arranging and presenting presenting presenting presenting presenting presenting presenting presenting presenting presenting presenting them in categories categories categories categories categories categories categories categories categories categories categories 

could utilize them most effectively. For this approach to succeed, could utilize utilize utilize utilize utilize utilize utilize utilize utilize utilize utilize utilize them most effectively fectively fectively fectively fectively fectively fectively fectively fectively fectively fectively fectively. For this approach approach approach approach approach approach approach approach approach approach approach approach to succeed, succeed, succeed, succeed, succeed, succeed, succeed, succeed, succeed, succeed, succeed, succeed, 

though, the defi nition of each category needs to be broadly un- though, though, though, though, though, though, though, though, though, though, though, the definition of each category category category category category category category category category category category needs to be broadly broadly broadly broadly broadly broadly broadly broadly broadly broadly broadly understood. For example, the defi nition of Process can have many derstood. derstood. derstood. derstood. derstood. derstood. derstood. derstood. derstood. derstood. derstood. derstood. For example, example, example, example, example, example, example, example, example, example, example, example, the definition of Process Process Process Process Process Process Process Process Process Process Process Process can have many 

different meanings. Process can range the gamut of bringing a different meanings. meanings. meanings. meanings. meanings. meanings. meanings. meanings. meanings. meanings. meanings. Process Process Process Process Process Process Process Process Process Process Process can range the gamut of bringing bringing bringing bringing bringing bringing bringing bringing bringing bringing bringing a 

legal action against somebody or treating light-sensitive fi lm or legal action against against against against against against against against against against against somebody somebody somebody somebody somebody somebody somebody somebody somebody somebody somebody or treating treating treating treating treating treating treating treating treating treating treating light-sensitive light-sensitive light-sensitive light-sensitive light-sensitive light-sensitive light-sensitive light-sensitive light-sensitive light-sensitive light-sensitive film or 

paper with chemicals. The Team initially developed fi ve catego- paper with chemicals. chemicals. chemicals. chemicals. chemicals. chemicals. chemicals. chemicals. chemicals. chemicals. chemicals. chemicals. The Team initially initially initially initially initially initially initially initially initially initially initially initially developed developed developed developed developed developed developed developed developed developed developed developed five catego- catego- catego- catego- catego- catego- catego- catego- catego- catego- catego- categories to organize the R-O-Fs, but after extensive analysis of the ries to organize the R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, but after extensive extensive extensive extensive extensive extensive extensive extensive extensive extensive extensive analysis analysis analysis analysis analysis analysis analysis analysis analysis analysis analysis of the 

NASA workforce inputs from Safety and Mission Success Week, NASA workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce inputs from Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Success Success Success Success Success Success Success Success Success Success Success Success Week, 

the framework was revised to one made up of seven categories. the framework framework framework framework framework framework framework framework framework framework framework was revised revised revised revised revised revised revised revised revised revised revised to one made up of seven categories. categories. categories. categories. categories. categories. categories. categories. categories. categories. categories. 

Each of these is defi ned in Table 9. Each of these is defined in Table 9.

2.4 TEAM DISCUSSIONS ISCUSSIONS

The Team met throughout the Fall of 2003 and structured its The Team met throughout throughout throughout throughout throughout throughout throughout throughout throughout throughout throughout the Fall of 2003 and structured structured structured structured structured structured structured structured structured structured structured its 

discussions around the R-O-Fs in the CAIB Report. To facilitate discussions discussions discussions discussions discussions discussions discussions discussions discussions discussions discussions discussions around the R-O-Fs in the CAIB Report. Report. Report. Report. Report. Report. Report. Report. Report. Report. Report. Report. To facilitate facilitate facilitate facilitate facilitate facilitate facilitate facilitate facilitate facilitate facilitate facilitate 

its discussions, it created the CAIB Agency-wide Action Matrix its discussions, discussions, discussions, discussions, discussions, discussions, discussions, discussions, discussions, discussions, discussions, it created created created created created created created created created created created the CAIB Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Action Matrix 

(Diaz Team Matrix, or simply, “The Matrix”), which is included (Diaz Team Matrix, Matrix, Matrix, Matrix, Matrix, Matrix, Matrix, Matrix, Matrix, Matrix, Matrix, Matrix, or simply, “The Matrix”), Matrix”), Matrix”), Matrix”), Matrix”), Matrix”), Matrix”), Matrix”), Matrix”), Matrix”), Matrix”), Matrix”), which is included included included included included included included included included included included included 

as Appendix A of this Report. The Diaz Team Matrix is a table as Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix A of this Report. Report. Report. Report. Report. Report. Report. Report. Report. Report. Report. The Diaz Team Matrix is a table 

that lists each R-O-F in the CAIB Report. It includes the:

• CAIB reference number;

• CAIB description of the R-O-F;

• Discussion of why the Team believes the R-O-F was Discussion of why the Team believes the R-O-F was 

broadly applicable;

• Recommended action to address the R-O-F; and

• NASA Headquarters organization assigned the action. NASA Headquarters organization assigned the action.

The matrix also includes a Team-assigned number for each cat- The matrix also includes includes includes includes includes includes includes includes includes includes includes includes a Team-assigned eam-assigned eam-assigned eam-assigned eam-assigned eam-assigned eam-assigned eam-assigned eam-assigned eam-assigned eam-assigned eam-assigned number for each category of R-O-F. (1 – 29 recommendations, 1 – 27 observations egory of R-O-F. (1 – 29 recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, 1 – 27 observations observations observations observations observations observations observations observations observations observations observations 

and 1 – 137 fi ndings.) Of the 193 R-O-Fs in the CAIB Report, the and 1 – 137 findings.) ndings.) ndings.) ndings.) ndings.) ndings.) ndings.) ndings.) ndings.) ndings.) ndings.) Of the 193 R-O-Fs in the CAIB Report, Report, Report, Report, Report, Report, Report, Report, Report, Report, Report, the 

Team identifi ed 13 of the 29 recommendations, 8 of the 27 ob- Team identifi identifi identifi identifi identifi identifi identifi identifi identifi identifi identifi identified 13 of the 29 recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, 8 of the 27 observations and 64 of the 137 fi ndings as having broad application servations servations servations servations servations servations servations servations servations servations servations and 64 of the 137 findings as having broad application application application application application application application application application application application 

2.0 INTRODUCTION
2 0

across the Agency. The 85 broadly applicable R-O-Fs resulted in across the Agency. The 85 broadly broadly broadly broadly broadly broadly broadly broadly broadly broadly broadly applicable applicable applicable applicable applicable applicable applicable applicable applicable applicable applicable R-O-Fs resulted resulted resulted resulted resulted resulted resulted resulted resulted resulted resulted in 

40 specifi c actions described in the Diaz Team Matrix. (Note that 40 specifi specic actions actions actions actions actions actions actions actions actions actions actions described described described described described described described described described described described in the Diaz Team Matrix. Matrix. Matrix. Matrix. Matrix. Matrix. Matrix. Matrix. Matrix. Matrix. Matrix. (Note that 

in some cases an action addressed more than one R-O-F. Hence, in some cases an action addressed addressed addressed addressed addressed addressed addressed addressed addressed addressed addressed addressed more than one R-O-F. Hence, 

85 R-O-Fs and 40 recommended actions.)

2.5 SAFETY AND MISSION SUCCESS WEEK

The broad applicability of many of the CAIB Report R-O-Fs was The broad applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability of many of the CAIB Report R-O-Fs was 

apparent to the Diaz Team very early in its effort. As the Teamʼs apparent apparent apparent apparent apparent apparent apparent apparent apparent apparent apparent apparent to the Diaz Team very early in its effort. As the Teamʼs 

discussions continued, it realized that members of the entire discussions discussions discussions discussions discussions discussions discussions discussions discussions discussions discussions continued, continued, continued, continued, continued, continued, continued, continued, continued, continued, continued, it realized realized realized realized realized realized realized realized realized realized realized that members members members members members members members members members members members of the entire 

NASA workforce could benefi t from reading the CAIB Report NASA workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce could benefit from reading reading reading reading reading reading reading reading reading reading reading the CAIB Report 

and discussing its implications with their peers and supervisors. and discussing discussing discussing discussing discussing discussing discussing discussing discussing discussing discussing discussing its implications implications implications implications implications implications implications implications implications implications implications implications with their peers and supervisors. supervisors. supervisors. supervisors. supervisors. supervisors. supervisors. supervisors. supervisors. supervisors. supervisors. supervisors. 

Initially, the Team discussed the possibility of recommending a Initially Initially Initially Initially Initially Initially Initially Initially Initially Initially Initially, the Team discussed discussed discussed discussed discussed discussed discussed discussed discussed discussed discussed the possibility possibility possibility possibility possibility possibility possibility possibility possibility possibility possibility of recommending recommending recommending recommending recommending recommending recommending recommending recommending recommending recommending a 

“NASA Stand Down Day,” which would be devoted to discus- “NASA Stand Down Day,” which would be devoted devoted devoted devoted devoted devoted devoted devoted devoted devoted devoted devoted to discus- discus- discus- discus- discus- discus- discus- discus- discus- discus- discus- discussions about the CAIB Report at each NASA Center and facility. sions about the CAIB Report at each NASA Center and facility facility facility facility facility facility facility facility facility facility facility. 

However, it was felt that a more effective way to accomplish the However However However However However However However However However However However However, it was felt that a more effective fective fective fective fective fective fective fective fective fective fective fective way to accomplish accomplish accomplish accomplish accomplish accomplish accomplish accomplish accomplish accomplish accomplish accomplish the 

intent of the activity was through discussions at the work-unit intent of the activity activity activity activity activity activity activity activity activity activity activity was through through through through through through through through through through through discussions discussions discussions discussions discussions discussions discussions discussions discussions discussions discussions at the work-unit work-unit work-unit work-unit work-unit work-unit work-unit work-unit work-unit work-unit work-unit 

level in each organization. Therefore, the Team recommended level in each organization. ganization. ganization. ganization. ganization. ganization. ganization. ganization. ganization. ganization. ganization. Therefore, Therefore, Therefore, Therefore, Therefore, Therefore, Therefore, Therefore, Therefore, Therefore, Therefore, the Team recommended recommended recommended recommended recommended recommended recommended recommended recommended recommended recommended 

a week-long activity, the Safety and Mission Success Week, a week-long week-long week-long week-long week-long week-long week-long week-long week-long week-long week-long activity activity activity activity activity activity activity activity activity activity activity, the Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Success Success Success Success Success Success Success Success Success Success Success Week, 

during which all civil servant and contractor employees across during which all civil servant servant servant servant servant servant servant servant servant servant servant and contractor contractor contractor contractor contractor contractor contractor contractor contractor contractor contractor employees employees employees employees employees employees employees employees employees employees employees across 

the Agency would be given the opportunity to discuss the CAIB the Agency would be given the opportunity opportunity opportunity opportunity opportunity opportunity opportunity opportunity opportunity opportunity opportunity opportunity to discuss discuss discuss discuss discuss discuss discuss discuss discuss discuss discuss discuss the CAIB 

Report with their colleagues and supervisors. More specifi cally, Report with their colleagues colleagues colleagues colleagues colleagues colleagues colleagues colleagues colleagues colleagues colleagues and supervisors. supervisors. supervisors. supervisors. supervisors. supervisors. supervisors. supervisors. supervisors. supervisors. supervisors. More specifi specically, 

it would provide the opportunity to discuss the relevance of the it would provide provide provide provide provide provide provide provide provide provide provide provide the opportunity opportunity opportunity opportunity opportunity opportunity opportunity opportunity opportunity opportunity opportunity opportunity to discuss discuss discuss discuss discuss discuss discuss discuss discuss discuss discuss discuss the relevance relevance relevance relevance relevance relevance relevance relevance relevance relevance relevance relevance of the 

CAIB Report, how it impacts mission success in the work unit, CAIB Report, Report, Report, Report, Report, Report, Report, Report, Report, Report, Report, how it impacts impacts impacts impacts impacts impacts impacts impacts impacts impacts impacts mission mission mission mission mission mission mission mission mission mission mission success success success success success success success success success success success in the work unit, 

and most importantly, what each employee can do to address and most importantly importantly importantly importantly importantly importantly importantly importantly importantly importantly importantly importantly, what each employee employee employee employee employee employee employee employee employee employee employee employee can do to address address address address address address address address address address address address 

those impacts in his and her work unit.

The Diaz Team recognized that this was an opportunity to begin The Diaz Team recognized recognized recognized recognized recognized recognized recognized recognized recognized recognized recognized recognized that this was an opportunity opportunity opportunity opportunity opportunity opportunity opportunity opportunity opportunity opportunity opportunity opportunity to begin 

a dialog that each NASA Center and facility could then continue. a dialog that each NASA Center and facility facility facility facility facility facility facility facility facility facility facility could then continue. continue. continue. continue. continue. continue. continue. continue. continue. continue. continue. 

The Team also realized that the Safety and Mission Success The Team also realized realized realized realized realized realized realized realized realized realized that the Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Success Success Success Success Success Success Success Success Success Success 

Week would provide an excellent opportunity to present the Week would provide provide provide provide provide provide provide provide provide provide an excellent excellent excellent excellent excellent excellent excellent excellent excellent excellent opportunity opportunity opportunity opportunity opportunity opportunity opportunity opportunity opportunity opportunity to present present present present present present present present present present the 

Teamʼs initial fi ndings and goals about the broad applicability of Teamʼs initial initial initial initial initial initial initial initial initial initial initial findings and goals about the broad applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability of 

the CAIB Report R-O-Fs to the entire NASA workforce and get the CAIB Report R-O-Fs to the entire NASA workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce and get 

their feedback.

Safety and Mission Success Week was conducted across the Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Success Success Success Success Success Success Success Success Success Success Success Week was conducted conducted conducted conducted conducted conducted conducted conducted conducted conducted conducted across the 

Agency the week of November 17, 2003. The Diaz Team pro- Agency the week of November November November November November November November November November November 17, 2003. The Diaz Team provided guidance for conducting the discussions that week, and vided guidance guidance guidance guidance guidance guidance guidance guidance guidance guidance guidance for conducting conducting conducting conducting conducting conducting conducting conducting conducting conducting conducting the discussions discussions discussions discussions discussions discussions discussions discussions discussions discussions discussions that week, and 

established mechanisms for getting feedback at the NASA Head- established established established established established established established established established established mechanisms mechanisms mechanisms mechanisms mechanisms mechanisms mechanisms mechanisms mechanisms mechanisms for getting getting getting getting getting getting getting getting getting getting feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback at the NASA Headquarters, Center, and individual levels. The primary intent of the quarters, quarters, quarters, quarters, quarters, quarters, quarters, quarters, quarters, quarters, Center, and individual individual individual individual individual individual individual individual individual individual levels. levels. levels. levels. levels. levels. levels. levels. levels. levels. The primary primary primary primary primary primary primary primary primary primary intent of the 

feedback was to provide NASA Management with information it feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback was to provide provide provide provide provide provide provide provide provide provide provide NASA Management Management Management Management Management Management Management Management Management Management Management with information information information information information information information information information information information it 

could use to address opportunities for improvement at the NASA could use to address address address address address address address address address address opportunities opportunities opportunities opportunities opportunities opportunities opportunities opportunities opportunities opportunities for improvement improvement improvement improvement improvement improvement improvement improvement improvement improvement at the NASA

Headquarters and Center organizational levels, as identifi ed by Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters and Center organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational levels, levels, levels, levels, levels, levels, levels, levels, levels, levels, levels, as identifi identifi identifi identifi identifi identifi identifi identifi identifi identifi identified by 

their employees. The NASA Headquarters and Center organiza- their employees. employees. employees. employees. employees. employees. employees. employees. employees. employees. The NASA Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters and Center organiza- ganiza- ganiza- ganiza- ganiza- ganiza- ganiza- ganiza- ganiza- ganizations then provided the Diaz Team with a set of summarized tions then provided provided provided provided provided provided provided provided provided provided provided the Diaz Team with a set of summarized summarized summarized summarized summarized summarized summarized summarized summarized summarized summarized 

comments refl ecting the prevailing themes that emerged during comments comments comments comments comments comments comments comments comments comments reflecting the prevailing prevailing prevailing prevailing prevailing prevailing prevailing prevailing prevailing prevailing themes that emerged during 

the discussions. 

Based on the feedback received, the discussions conducted Based on the feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback received, received, received, received, received, received, received, received, received, received, the discussions discussions discussions discussions discussions discussions discussions discussions discussions discussions conducted conducted conducted conducted conducted conducted conducted conducted conducted conducted 

across NASA that week were very productive. In addition, the across NASA that week were very productive. productive. productive. productive. productive. productive. productive. productive. productive. productive. productive. In addition, addition, addition, addition, addition, addition, addition, addition, addition, addition, addition, the 

Safety and Mission Success Week feedback provided to the Diaz Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Success Success Success Success Success Success Success Success Success Success Week feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback provided provided provided provided provided provided provided provided provided provided to the Diaz 

Team confi rmed its approach and conclusions, and is discussed Team confirmed its approach approach approach approach approach approach approach approach approach approach approach and conclusions, conclusions, conclusions, conclusions, conclusions, conclusions, conclusions, conclusions, conclusions, conclusions, conclusions, and is discussed discussed discussed discussed discussed discussed discussed discussed discussed discussed discussed 

in general throughout this Report. The feedback also confi rmed in general general general general general general general general general general throughout throughout throughout throughout throughout throughout throughout throughout throughout throughout this Report. Report. Report. Report. Report. Report. Report. Report. Report. Report. The feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback also confirmed 

the Teamʼs assessment of major issue areas, which were expand- the Teamʼs assessment assessment assessment assessment assessment assessment assessment assessment assessment assessment assessment of major issue areas, which were expand- expand- expand- expand- expand- expand- expand- expand- expand- expand- expanded into the seven primary categories that are defi ned in Table 9 ed into the seven primary primary primary primary primary primary primary primary primary primary categories categories categories categories categories categories categories categories categories categories that are defined in Table 9 

and refl ected in this Report. and reflected in this Report.

It is important to note that any discussion of Safety and Mission It is important important important important important important important important important important to note that any discussion discussion discussion discussion discussion discussion discussion discussion discussion discussion of Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission 

Table 9. Organizing the R-O-Fs – the seven categories and their defi nitions. 

Leadership

Leadership is the action of inspiring, guiding, directing, or infl uencing people. Leadership is not a position in the 

hierarchy of management, but rather a series of behaviors and actions, which enables others to achieve goals 

and shared vision. Leadership occurs throughout all levels of an organization. 

Learning

Learning is the acquisition of knowledge or skill. It can be gained through formal education and training, 

experiences and expertise gained on-the-job, and through life-long experience. Learning outcomes can include 

the acquisition of knowledge and/or understanding, as well as changes in behavior.

Communication

Communication is the exchange of information between individuals, or groups by means of speaking, writing, 

or a common system of signs or behavior. One goal of communication is a sense of mutual understanding; both 

parties must speak the same language.

Processes 

and Rules

A process is a series of actions directed toward a particular aim, dealing with people or things. A process can 

also be the means to deal with somebody or something according to established procedures. Rules may be 

authoritative principles that govern individual or group behavior. Rules can also be used to ensure accountability, 

to establish authority within an organization, and to convey knowledge.

Technical 

Capabilities 

Technical capability is the set of abilities needed to accomplish specialized tasks, in fi elds such as industrial 

applications and applied science. It refers to skilled staff members and the methods, tools and resources they 

use to perform their work effectively. Technical capability is also the ability to employ a technique according to a 

strict interpretation of the rules. 

Organizational 

Structure

An organization is a group of people identifi ed by shared purpose. It defi nes the relationships among separate 

staff elements that are arranged in a coherent structure. An organizational structure, then, is the framework 

that enables a system made up of separate but interrelated parts to function as an orderly whole. For example, 

organizational structure describes the ways in which the constituent components of NASA are able to work 

together. 

Risk 

Management

Risk is the potential for injury, damage, or loss to individuals or property. Risk is also the statistical chance 

that such a hazard will occur, especially from the failure of an engineered system. Risk management is the 

systematic process of analyzing, quantifying, and managing risk as one would do with another resource available 

in the execution of a project.
2 1

Success Week feedback in this Report refl ects comments that Success Success Success Success Success Success Success Success Success Success Success Week feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback in this Report reflects comments comments comments comments comments comments comments comments comments comments comments that 

were received from more than one source. They refl ect themes were received received received received received received received received received received received from more than one source. source. source. source. source. source. source. source. source. source. source. They reflect themes 

that emerged in the feedback and therefore are not attributable that emerged in the feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback and therefore therefore therefore therefore therefore therefore therefore therefore therefore therefore therefore therefore are not attributable attributable attributable attributable attributable attributable attributable attributable attributable attributable attributable attributable 

to a specifi c individual. On the other hand, the statements may to a specifi specic individual. individual. individual. individual. individual. individual. individual. individual. individual. individual. individual. On the other hand, the statements statements statements statements statements statements statements statements statements statements statements may 

have come from a limited number of individuals and therefore have come from a limited limited limited limited limited limited limited limited limited limited limited limited number of individuals individuals individuals individuals individuals individuals individuals individuals individuals individuals individuals individuals and therefore therefore therefore therefore therefore therefore therefore therefore therefore therefore therefore therefore 

should not be construed as attitudes that represent the entire should not be construed construed construed construed construed construed construed construed construed construed construed as attitudes attitudes attitudes attitudes attitudes attitudes attitudes attitudes attitudes attitudes attitudes that represent represent represent represent represent represent represent represent represent represent represent the entire 

NASA workforce. NASA workforce.

2.6 REPORT LAYOUT

During the course of its discussions, the Team began to see major During the course of its discussions, discussions, discussions, discussions, discussions, discussions, discussions, discussions, discussions, discussions, discussions, the Team began to see major 

themes emerge, which were reinforced by the Safety and Mission themes emerge, which were reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced by the Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission 

Success Week feedback. As a result, it grouped the 85 broadly Success Success Success Success Success Success Success Success Success Success Success Week feedback. feedback. feedback. feedback. feedback. feedback. feedback. feedback. feedback. feedback. feedback. As a result, result, result, result, result, result, result, result, result, result, result, it grouped grouped grouped grouped grouped grouped grouped grouped grouped grouped grouped the 85 broadly broadly broadly broadly broadly broadly broadly broadly broadly broadly broadly 

applicable R-O-Fs and their resulting actions into the following applicable applicable applicable applicable applicable applicable applicable applicable applicable applicable applicable applicable R-O-Fs and their resulting resulting resulting resulting resulting resulting resulting resulting resulting resulting resulting resulting actions actions actions actions actions actions actions actions actions actions actions actions into the following following following following following following following following following following following following 

seven categories:

• Leadership

• Learning

• Communication

• Processes and Rules

• Technical Capabilities Technical Capabilities

• Organizational Structure Organizational Structure

• Risk Management

The chapters in this Report are aligned with those categories. The chapters chapters chapters chapters chapters chapters chapters chapters chapters chapters chapters in this Report are aligned aligned aligned aligned aligned aligned aligned aligned aligned aligned aligned with those categories. categories. categories. categories. categories. categories. categories. categories. categories. categories. categories. 

Each chapter:

• Cites a key statement from the CAIB Report related to 

the category. the category.

• Summarizes the issues related to the category that have 

Agency-wide application.

• Provides a discussion of examples from the CAIB 

Report that describes the issues related to this category. Report that describes the issues related to this category.

• Provides a summary of the Teamʼs discussion and Provides a summary of the Teamʼs discussion and 

why they feel the R-O-Fs in this category have broad 

Agency-wide application as supported by Safety and 

Mission Success Week feedback. Mission Success Week feedback.

• Provides a goal for the category suggested by the team. 

(It should be noted that these are in addition to the 

Diaz Team Matrix actions for the broadly applicable Diaz Team Matrix actions for the broadly applicable 

CAIB R-O-Fs.)

• Summarizes the R-O-Fs that are broadly applicable for 

each of the seven categories.

Each chapter also includes a diagram which highlights key state- Each chapter chapter chapter chapter chapter chapter chapter chapter chapter chapter chapter chapter also includes includes includes includes includes includes includes includes includes includes includes includes a diagram diagram diagram diagram diagram diagram diagram diagram diagram diagram diagram diagram which highlights highlights highlights highlights highlights highlights highlights highlights highlights highlights highlights highlights key statements from the CAIB Report, how many R-O-Fs in this category ments from the CAIB Report, Report, Report, Report, Report, Report, Report, Report, Report, Report, Report, how many R-O-Fs in this category category category category category category category category category category category 

were identifi ed as broadly applicable, how many recommended were identifi identifi identifi identifi identifi identifi identifi identifi identifi identifi identifi identified as broadly broadly broadly broadly broadly broadly broadly broadly broadly broadly broadly broadly applicable, applicable, applicable, applicable, applicable, applicable, applicable, applicable, applicable, applicable, applicable, applicable, how many recommended recommended recommended recommended recommended recommended recommended recommended recommended recommended recommended recommended 

actions resulted from these R-O-Fs, and workforce feedback re- actions actions actions actions actions actions actions actions actions actions actions resulted resulted resulted resulted resulted resulted resulted resulted resulted resulted resulted from these R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, and workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback received during Safety and Mission Success Week that confi rmed ceived during Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Success Success Success Success Success Success Success Success Success Success Success Week that confirmed 

the issues in this category apply broadly across NASA.
2 2

CAIB Report Chapter 8, p203:

Leaders create culture. It is their responsibility to change it. Top administrators must take responsibility for risk, 

failure, and safety by remaining alert to the effects their decisions have on the system. Leaders are responsible 

for establishing the conditions that lead to their subordinates’ successes or failures.

Management practices are a cause of the accident.

Agency-wide Themes

• Leaders must lead by example, creating conditions 

and a culture for safety and mission success.

• Leaders must balance schedule and risk.

• Leaders should allow and encourage diversity of 

views, eliminate retribution towards those with 

differing opinions, and understand that ”No” is an 

acceptable answer.

• Leaders should be grown throughout all levels of 

the organization, through succession planning and 

developmental experiences.

`

3.1 INTRODUCTION NTRODUCTION

NASA has a strong heritage for developing leaders at all levels NASA has a strong heritage heritage heritage heritage heritage heritage heritage heritage heritage heritage heritage for developing developing developing developing developing developing developing developing developing developing developing leaders leaders leaders leaders leaders leaders leaders leaders leaders leaders leaders at all levels 

of the Agency who have a “can-do” attitude. They have brought of the Agency who have a “can-do” “can-do” “can-do” “can-do” “can-do” “can-do” “can-do” “can-do” “can-do” “can-do” “can-do” “can-do” attitude. attitude. attitude. attitude. attitude. attitude. attitude. attitude. attitude. attitude. attitude. attitude. They have brought brought brought brought brought brought brought brought brought brought brought brought 

our Nation to the Moon and back, launched and managed hun- our Nation to the Moon and back, launched launched launched launched launched launched launched launched launched launched launched and managed managed managed managed managed managed managed managed managed managed managed hundreds of safe and successful human and unmanned missions to dreds of safe and successful successful successful successful successful successful successful successful successful successful successful successful human and unmanned unmanned unmanned unmanned unmanned unmanned unmanned unmanned unmanned unmanned unmanned unmanned missions missions missions missions missions missions missions missions missions missions missions missions to 

space, led us through seemingly hopeless situations like Apollo space, led us through through through through through through through through through through through seemingly seemingly seemingly seemingly seemingly seemingly seemingly seemingly seemingly seemingly seemingly hopeless hopeless hopeless hopeless hopeless hopeless hopeless hopeless hopeless hopeless hopeless situations situations situations situations situations situations situations situations situations situations situations like Apollo 

13, and begun the complex construction and operation of the In- 13, and begun the complex complex complex complex complex complex complex complex complex complex complex complex construction construction construction construction construction construction construction construction construction construction construction construction and operation operation operation operation operation operation operation operation operation operation operation operation of the International Space Station. However, with the seriousness of the ternational ternational ternational ternational ternational ternational ternational ternational ternational ternational ternational Space Station. Station. Station. Station. Station. Station. Station. Station. Station. Station. Station. However However However However However However However However However However However, with the seriousness seriousness seriousness seriousness seriousness seriousness seriousness seriousness seriousness seriousness seriousness of the 

Columbia accident and the CAIB Report, NASA leaders need to accident accident accident accident accident accident accident accident accident and the CAIB Report, Report, Report, Report, Report, Report, Report, Report, Report, NASA leaders leaders leaders leaders leaders leaders leaders leaders leaders need to 

refl ect upon and grow from the lessons learned. The Diaz Teamʼs reflect upon and grow from the lessons lessons lessons lessons lessons lessons lessons lessons lessons lessons lessons lessons learned. learned. learned. learned. learned. learned. learned. learned. learned. learned. learned. learned. The Diaz Teamʼs 

actions contained in the Diaz Team Matrix require that everyone actions actions actions actions actions actions actions actions actions actions actions contained contained contained contained contained contained contained contained contained contained contained in the Diaz Team Matrix require require require require require require require require require require require that everyone everyone everyone everyone everyone everyone everyone everyone everyone everyone everyone 

understand their responsibilities and are given the authority to understand understand understand understand understand understand understand understand understand understand understand understand their responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities and are given the authority authority authority authority authority authority authority authority authority authority authority authority to 

perform their jobs, with the accountability for their individual perform perform perform perform perform perform perform perform perform perform perform their jobs, with the accountability accountability accountability accountability accountability accountability accountability accountability accountability accountability accountability for their individual individual individual individual individual individual individual individual individual individual individual 

and programʼs successes and failures, including lessons learned. and programʼ programʼ programʼ programʼ programʼ programʼ programʼ programʼ programʼ programʼ programʼ programʼs successes successes successes successes successes successes successes successes successes successes successes successes and failures, failures, failures, failures, failures, failures, failures, failures, failures, failures, failures, failures, including including including including including including including including including including including including lessons lessons lessons lessons lessons lessons lessons lessons lessons lessons lessons lessons learned. learned. learned. learned. learned. learned. learned. learned. learned. learned. learned. learned. 

Leadership means being able to make decisions, support those Leadership Leadership Leadership Leadership Leadership Leadership Leadership Leadership Leadership Leadership Leadership means being able to make decisions, decisions, decisions, decisions, decisions, decisions, decisions, decisions, decisions, decisions, decisions, support support support support support support support support support support support those 

decisions, and be accountable for the outcome. It also means decisions, decisions, decisions, decisions, decisions, decisions, decisions, decisions, decisions, decisions, decisions, and be accountable accountable accountable accountable accountable accountable accountable accountable accountable accountable accountable for the outcome. outcome. outcome. outcome. outcome. outcome. outcome. outcome. outcome. outcome. outcome. It also means 

making informed decisions and treating staff and contrac- making informed informed informed informed informed informed informed informed informed informed informed decisions decisions decisions decisions decisions decisions decisions decisions decisions decisions decisions and treating treating treating treating treating treating treating treating treating treating treating staff and contrac- contrac- contrac- contrac- contrac- contrac- contrac- contrac- contrac- contrac- contractor support with respect and courtesy to ensure that everyone tor support support support support support support support support support support support with respect respect respect respect respect respect respect respect respect respect respect and courtesy courtesy courtesy courtesy courtesy courtesy courtesy courtesy courtesy courtesy courtesy to ensure that everyone everyone everyone everyone everyone everyone everyone everyone everyone everyone everyone 

understands their inputs are valued and important. It involves understands understands understands understands understands understands understands understands understands understands understands understands their inputs are valued and important. important. important. important. important. important. important. important. important. important. important. important. It involves involves involves involves involves involves involves involves involves involves involves involves 

empowering and developing the workforce, listening and com- empowering empowering empowering empowering empowering empowering empowering empowering empowering empowering empowering and developing developing developing developing developing developing developing developing developing developing developing the workforce, workforce, workforce, workforce, workforce, workforce, workforce, workforce, workforce, workforce, workforce, listening listening listening listening listening listening listening listening listening listening listening and communicating with them more effectively, and developing future municating municating municating municating municating municating municating municating municating municating municating municating with them more effectively fectively fectively fectively fectively fectively fectively fectively fectively fectively fectively fectively, and developing developing developing developing developing developing developing developing developing developing developing developing future 

leaders through progressive leadership development and effec- leaders leaders leaders leaders leaders leaders leaders leaders leaders leaders leaders through through through through through through through through through through through progressive progressive progressive progressive progressive progressive progressive progressive progressive progressive progressive leadership leadership leadership leadership leadership leadership leadership leadership leadership leadership leadership development development development development development development development development development development development and effective organization succession planning and practices. Leadership tive organization ganization ganization ganization ganization ganization ganization ganization ganization ganization ganization ganization succession succession succession succession succession succession succession succession succession succession succession succession planning planning planning planning planning planning planning planning planning planning planning planning and practices. practices. practices. practices. practices. practices. practices. practices. practices. practices. practices. practices. Leadership Leadership Leadership Leadership Leadership Leadership Leadership Leadership Leadership Leadership Leadership Leadership 

means creating a climate and conditions for NASA employees means creating creating creating creating creating creating creating creating creating creating creating a climate climate climate climate climate climate climate climate climate climate climate and conditions conditions conditions conditions conditions conditions conditions conditions conditions conditions conditions for NASA employees employees employees employees employees employees employees employees employees employees employees 

and organizations to achieve safety and mission success. and organizations to achieve safety and mission success.

3.2 CATEGORY ATEGORY R-O-F S R-O-F SUMMARY

Overall there were no recommendations, three observations, and Overall Overall Overall Overall Overall Overall Overall Overall Overall Overall Overall there were no recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, three observations, observations, observations, observations, observations, observations, observations, observations, observations, observations, observations, and 

14 fi ndings that the Diaz Team determined had broad NASA 14 findings that the Diaz Team determined determined determined determined determined determined determined determined determined determined determined determined had broad NASA

applicability to Leadership. Table 11 shows these 17 R-O-Fs in applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability to Leadership. Leadership. Leadership. Leadership. Leadership. Leadership. Leadership. Leadership. Leadership. Leadership. Leadership. Table 11 shows these 17 R-O-Fs in 

brief summary statement form, along with brief discussion points brief summary summary summary summary summary summary summary summary summary summary summary summary statement statement statement statement statement statement statement statement statement statement statement statement form, along with brief discussion discussion discussion discussion discussion discussion discussion discussion discussion discussion discussion discussion points 

on NASA applicability. Four themes emerge from these discus- on NASA applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability. Four themes emerge from these discus- discus- discus- discus- discus- discus- discus- discus- discus- discus- discussion points as shown above.

3.3 DISCUSSION ISCUSSION

The need for improved leadership practices at NASA permeates The need for improved improved improved improved improved improved improved improved improved improved leadership leadership leadership leadership leadership leadership leadership leadership leadership leadership practices practices practices practices practices practices practices practices practices practices at NASA permeates permeates permeates permeates permeates permeates permeates permeates permeates permeates 

the entire CAIB Report and can be found in a broad number of the entire CAIB Report and can be found in a broad number of 

the Report fi ndings and observations. Threaded throughout the the Report findings and observations. observations. observations. observations. observations. observations. observations. observations. observations. observations. Threaded Threaded Threaded Threaded Threaded Threaded Threaded Threaded Threaded Threaded throughout throughout throughout throughout throughout throughout throughout throughout throughout throughout the 

Diaz Team Report chapters are discussions and goals for ways Diaz Team Report chapters chapters chapters chapters chapters chapters chapters chapters chapters chapters chapters are discussions discussions discussions discussions discussions discussions discussions discussions discussions discussions discussions and goals for ways 

to lead and manage more effectively. The Team recognizes that to lead and manage more effectively fectively fectively fectively fectively fectively fectively fectively fectively fectively. The Team recognizes recognizes recognizes recognizes recognizes recognizes recognizes recognizes recognizes recognizes that 

an overarching theme of the CAIB Report is leadership and an overarching overarching overarching overarching overarching overarching overarching overarching overarching overarching overarching theme of the CAIB Report is leadership leadership leadership leadership leadership leadership leadership leadership leadership leadership leadership and 

that to embark upon an aggressive agenda for change, NASA that to embark upon an aggressive aggressive aggressive aggressive aggressive aggressive aggressive aggressive aggressive aggressive agenda for change, change, change, change, change, change, change, change, change, change, NASA

leaders will require a framework of common understanding leaders leaders leaders leaders leaders leaders leaders leaders leaders leaders will require require require require require require require require require require a framework framework framework framework framework framework framework framework framework framework of common understanding understanding understanding understanding understanding understanding understanding understanding understanding understanding 

and approach. When addressing the major changes required by and approach. approach. approach. approach. approach. approach. approach. approach. approach. approach. approach. When addressing addressing addressing addressing addressing addressing addressing addressing addressing addressing addressing the major changes changes changes changes changes changes changes changes changes changes changes required required required required required required required required required required required by 

NASA leaders to fulfi ll the CAIB Report implied mandate, the NASA leaders leaders leaders leaders leaders leaders leaders leaders leaders leaders to fulfill the CAIB Report implied implied implied implied implied implied implied implied implied implied mandate, mandate, mandate, mandate, mandate, mandate, mandate, mandate, mandate, mandate, the 

eight stages of leading change cited by John Kotter in his book eight stages of leading leading leading leading leading leading leading leading leading leading leading change cited by John Kotter in his book 

Leading Change Leading Change may be applicable to NASA leaders and the may be applicable applicable applicable applicable applicable applicable applicable applicable to NASA leaders leaders leaders leaders leaders leaders leaders leaders and the 

challenges they face:

1. Establish a sense of urgency for the change we must Establish a sense of urgency for the change we must 

undertake as a result of the accident and CAIB Report;

2. Create a team-based coalition to lead the change;

3. Develop a shared vision and strategy for the change 

effort; effort;

4. Communicate the change and the associated changed 

behaviors and practices;

5. Empower the workforce to undertake the envisioned 

changes, ridding ourselves of obstacles, changing 

systems and structures that undermine the changes, and systems systems systems systems systems systems systems systems systems and structures structures structures structures structures structures structures structures structures that undermine undermine undermine undermine undermine undermine undermine undermine undermine the changes, changes, changes, changes, changes, changes, changes, changes, changes, and 

encouraging risk taking within agreed-upon thresholds;

6. Recognize the workforce for visible improvements;

7. Align systems, structures, policies, people, and projects with the new vision; and,

8. Anchor the new approaches in the changing culture 

through connections between new behaviors and 

organizational success and leadership development and organizational success and leadership development and 

succession.

Based on the CAIB Report R-O-Fs and best leadership practices, Based on the CAIB Report R-O-Fs and best leadership leadership leadership leadership leadership leadership leadership leadership leadership leadership leadership practices, practices, practices, practices, practices, practices, practices, practices, practices, practices, practices, 

the Team has identifi ed several means to assure NASAʼs leader- the Team has identifi identifi identifi identifi identifi identifi identifi identifi identifi identified several several several several several several several several several several means to assure NASAʼs leadership. The Team believes NASAʼs leadership for the future is quite ship. The Team believes believes believes believes believes believes believes believes believes believes believes NASAʼs leadership leadership leadership leadership leadership leadership leadership leadership leadership leadership leadership for the future is quite 

promising based on the talent we have, we will recruit, and we promising promising promising promising promising promising promising promising promising promising based on the talent we have, we will recruit, recruit, recruit, recruit, recruit, recruit, recruit, recruit, recruit, recruit, and we 

will develop. The insights NASA leaders have gained from the will develop. develop. develop. develop. develop. develop. develop. develop. develop. develop. develop. The insights insights insights insights insights insights insights insights insights insights insights NASA leaders leaders leaders leaders leaders leaders leaders leaders leaders leaders leaders have gained from the 

accident and the CAIB Report and the knowledge gained from accident accident accident accident accident accident accident accident accident accident and the CAIB Report and the knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge gained from 

studying and applying best leadership practices will help them studying studying studying studying studying studying studying studying studying studying and applying applying applying applying applying applying applying applying applying applying best leadership leadership leadership leadership leadership leadership leadership leadership leadership leadership practices practices practices practices practices practices practices practices practices practices will help them 

to build a leadership philosophy and culture that supports safety to build a leadership leadership leadership leadership leadership leadership leadership leadership leadership leadership philosophy philosophy philosophy philosophy philosophy philosophy philosophy philosophy philosophy philosophy and culture culture culture culture culture culture culture culture culture culture that supports supports supports supports supports supports supports supports supports supports safety 

and mission success for the Nationʼs future space program. and mission success for the Nationʼs future space program.

The criteria used to delineate those R-O-Fs that were applied to The criteria criteria criteria criteria criteria criteria criteria criteria criteria criteria used to delineate delineate delineate delineate delineate delineate delineate delineate delineate delineate those R-O-Fs that were applied applied applied applied applied applied applied applied applied applied to 

leadership included the themes above and a leaderʼs ability to leadership leadership leadership leadership leadership leadership leadership leadership leadership leadership leadership included included included included included included included included included included included the themes above and a leaderʼs ability ability ability ability ability ability ability ability ability ability ability to 

make and support decisions. These criteria also pointed to the make and support support support support support support support support support support decisions. decisions. decisions. decisions. decisions. decisions. decisions. decisions. decisions. decisions. These criteria criteria criteria criteria criteria criteria criteria criteria criteria criteria also pointed pointed pointed pointed pointed pointed pointed pointed pointed pointed to the 

required behaviors of desirable leaders, their ability to model required required required required required required required required required required required behaviors behaviors behaviors behaviors behaviors behaviors behaviors behaviors behaviors behaviors behaviors of desirable desirable desirable desirable desirable desirable desirable desirable desirable desirable desirable leaders, leaders, leaders, leaders, leaders, leaders, leaders, leaders, leaders, leaders, leaders, their ability ability ability ability ability ability ability ability ability ability ability to model 

good leadership traits, and their ability to mentor subordinates good leadership leadership leadership leadership leadership leadership leadership leadership leadership leadership traits, traits, traits, traits, traits, traits, traits, traits, traits, traits, and their ability ability ability ability ability ability ability ability ability ability to mentor subordinates subordinates subordinates subordinates subordinates subordinates subordinates subordinates subordinates subordinates 

in support of effective leadership succession transitions. These in support support support support support support support support support support of effective fective fective fective fective fective fective fective fective fective leadership leadership leadership leadership leadership leadership leadership leadership leadership leadership succession succession succession succession succession succession succession succession succession succession transitions. transitions. transitions. transitions. transitions. transitions. transitions. transitions. transitions. transitions. These 

criteria address:

3.0 LEADERSHIP
2 3
2 4

• Empowerment by understanding and communicating 

responsibility, accountability, and authority. responsibility, accountability, and authority.

• Serving as an example and role model to employees 

by understanding and following the rules (but not 

“blindly”), and having a willingness to challenge the 

rules when safety and mission success are at stake.

• A willingness and ability to challenge schedules when A willingness and ability to challenge schedules when 

appropriate and necessary based upon well thought-out 

and presented analyses of risks.

• Respect of others and fostering fair consideration of all 

points of view. points of view.

The feedback from Safety and Mission Success Week reinforced The feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback from Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Success Success Success Success Success Success Success Success Success Success Success Week reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced 

the Diaz Team assessment: the Diaz Team assessment:

» We need to make sure every voice is heard without We need to make sure every voice is heard without 

fear of retaliation or suppression.

» NASA leadership has become preoccupied by actions NASA leadership has become preoccupied by actions 

to address symptoms; we need the resources and leadership commitment to fi x underlying causes. ership commitment to fix underlying causes.

» We need to stress among NASA leadership the impor- We need to stress among NASA leadership the importance of responding to even the lowest-level question. 

This was exactly why NASA did not exercise addition- This was exactly why NASA did not exercise additional techniques with Columbia to research the problem.

Throughout its Report, particularly in the “Organizational Cause Throughout Throughout Throughout Throughout Throughout Throughout Throughout Throughout Throughout Throughout its Report, Report, Report, Report, Report, Report, Report, Report, Report, Report, particularly particularly particularly particularly particularly particularly particularly particularly particularly particularly in the “Organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational Cause 

Statement,” the CAIB emphasizes that many of NASAʼs chal- Statement,” Statement,” Statement,” Statement,” Statement,” Statement,” Statement,” Statement,” Statement,” Statement,” the CAIB emphasizes emphasizes emphasizes emphasizes emphasizes emphasizes emphasizes emphasizes emphasizes emphasizes that many of NASAʼs challenges for today and the future relate to its culture, which will lenges for today and the future relate to its culture, culture, culture, culture, culture, culture, culture, culture, culture, culture, culture, which will 

require the Agencyʼs reliance on: sound engineering practices; require require require require require require require require require require the Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼs reliance reliance reliance reliance reliance reliance reliance reliance reliance reliance on: sound engineering engineering engineering engineering engineering engineering engineering engineering engineering engineering practices; practices; practices; practices; practices; practices; practices; practices; practices; practices; 

effective communication; employee empowerment; integrated effective fective fective fective fective fective fective fective fective fective fective communication; communication; communication; communication; communication; communication; communication; communication; communication; communication; communication; employee employee employee employee employee employee employee employee employee employee employee empowerment; empowerment; empowerment; empowerment; empowerment; empowerment; empowerment; empowerment; empowerment; empowerment; empowerment; integrated integrated integrated integrated integrated integrated integrated integrated integrated integrated integrated 

management across programmatic and organizational elements; management management management management management management management management management management across programmatic programmatic programmatic programmatic programmatic programmatic programmatic programmatic programmatic programmatic and organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational elements; elements; elements; elements; elements; elements; elements; elements; elements; elements; 

and adherence to well-defi ned rules and standards of operations. and adherence to well-defined rules and standards of operations. 

In addition, in direct response to concerns expressed by the CAIB In addition, addition, addition, addition, addition, addition, addition, addition, addition, addition, in direct response response response response response response response response response response to concerns concerns concerns concerns concerns concerns concerns concerns concerns concerns expressed expressed expressed expressed expressed expressed expressed expressed expressed expressed by the CAIB 

and individuals in the workforce during Safety and Mission Suc- and individuals individuals individuals individuals individuals individuals individuals individuals individuals individuals individuals in the workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce during Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Success Week, the Diaz Team believes that it would be worthwhile cess Week, the Diaz Team believes believes believes believes believes believes believes believes believes believes that it would be worthwhile worthwhile worthwhile worthwhile worthwhile worthwhile worthwhile worthwhile worthwhile worthwhile 

for the leadership of the Agency to confi rm that the processes in for the leadership leadership leadership leadership leadership leadership leadership leadership leadership leadership leadership of the Agency to confirm that the processes processes processes processes processes processes processes processes processes processes processes in 

place or anticipated are adequate to assure that programs contain place or anticipated anticipated anticipated anticipated anticipated anticipated anticipated anticipated anticipated anticipated are adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate to assure that programs programs programs programs programs programs programs programs programs programs contain contain contain contain contain contain contain contain contain contain 

the appropriate balance between requirements and resources. As the appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate balance balance balance balance balance balance balance balance balance balance balance between between between between between between between between between between between requirements requirements requirements requirements requirements requirements requirements requirements requirements requirements requirements and resources. resources. resources. resources. resources. resources. resources. resources. resources. resources. resources. As 

a consequence, the Team developed an additional goal which it a consequence, consequence, consequence, consequence, consequence, consequence, consequence, consequence, consequence, consequence, the Team developed developed developed developed developed developed developed developed developed developed an additional additional additional additional additional additional additional additional additional additional goal which it 

believes, when taken with others contained in this Report, will believes, believes, believes, believes, believes, believes, believes, believes, believes, believes, believes, when taken with others contained contained contained contained contained contained contained contained contained contained contained in this Report, Report, Report, Report, Report, Report, Report, Report, Report, Report, Report, will 

enhance the probability of mission success. This one goal is in- enhance enhance enhance enhance enhance enhance enhance enhance enhance enhance the probability probability probability probability probability probability probability probability probability probability of mission mission mission mission mission mission mission mission mission mission success. success. success. success. success. success. success. success. success. success. This one goal is included in Table 10. cluded in Table 10.

Table 10. The Diaz Team developed one goal for Leadership.

Leadership – Diaz Team Goal

The Agency should assess whether program management and budget formulation processes are adequate to assure there is an 

appropriate balance of requirements, resources, and risk to ensure safety and mission success.
2 5

Table 11. The Diaz Team determined that three Observations, and 14 Findings could be included in the Leadership Category resulting in seven actions.

Diaz 

Team # CAIB # CAIB Report Recommendations and Pertinent Factors Diaz Summary Discussion DiazAction # Responsible

O13 O10.6-2 NASA and USA must understand workforce 

and infrastructure requirements

NASA managers must match workforce and 

facility requirements against capabilities 14 J

O14 O10.6-3 Work with Air Force on management of 

aging systems

Organizations outside NASA can provide risk 

management lessons 15 AE

O27 O10.12-1 Implement strategy for leadership and 

management training

Agency-wide succession planning and 

leader development 17 F

F59 F6.1-4 Lack of effective project feedback processes 

for anomalies

Feedback mechanisms important for all 

programs

28 AE

F67 F6.2-1 NASA HQ focus was on ISS Node 2 launch 

date of Feb. 2004

Management decisions without 

understanding implications 30 AE

F69 F6.2-3 Capabilities stretched to limit to support 

schedule

Audit staffi ng practices and workforce 

management 32 AE

F71 F6.2-5 No schedule margin to accommodate for 

unforeseen problems

All programs need adequate schedule 

margin 33 AE

F72 F6.2-6 Node 2 schedule may have infl uenced 

manager’s decisions

Minority views and intuition are important 

information sources 28 AE

F75 F6.3-2 Outside imagery help requested on Flight 

Day 2

Streamlined communication needed for timecritical issues 28 AE

F79 F6.3-6 No MMT manager owned the Team’s actions Best practices defi ne accountability and 

responsibility 28 AE

F81 F6.3-8 Team routed imagery request through JSC 

MER

Clear lines of authority across organizations 

needed 28 AE

F82 F6.3-9 Team members never realized imagery 

decision was not fi nal

Rationale for decisions and feedback 

systems needed 28 AE

F85 F6.3-12 Damage assessments uncertain due to 

multiple failures Similar potential problems across Agency 28 AE

F88 F6.3-15 Lapses in leadership and communication for 

raising concerns Experts need to be heard and understood 28 AE

F91 F6.3-18 Foam not a problem confi rmed by expert, 

and no one questioned

Logical rationale to support conclusions 

needed 28 AE

F92 F6.3-19 “Who requested photos?” rather than merits 

of request asked

Merits of problems communicated to 

managers need response 28 AE

F95 F6.3-22 Engineers had to prove the system was 

unsafe rather than safe

Leaders need to develop process to address 

merit of problems 28 AE
2 6

NASA has not demonstrated the characteristics 

of a learning organization.

Agency-wide Themes

• NASA should provide robust simulation and emergency response training.

• Tools, databases, and models should be developed 

and used appropriately.

4.1 INTRODUCTION NTRODUCTION

Much was said in the CAIB Report about the NASA culture and Much was said in the CAIB Report about the NASA culture culture culture culture culture culture culture culture culture culture culture culture and 

how its attributes contributed to the how its attributes attributes attributes attributes attributes attributes contributed contributed contributed contributed contributed contributed to the Columbia accident. The accident. The 

Report specifi cally stated that NASA “has not demonstrated the Report specifi specically stated that NASA “has not demonstrated demonstrated demonstrated demonstrated demonstrated demonstrated demonstrated demonstrated demonstrated demonstrated demonstrated demonstrated the 

characteristics of a learning organization.” While there may be characteristics characteristics characteristics characteristics characteristics characteristics characteristics characteristics characteristics characteristics characteristics of a learning learning learning learning learning learning learning learning learning learning learning organization.” ganization.” ganization.” ganization.” ganization.” ganization.” ganization.” ganization.” ganization.” ganization.” ganization.” While there may be 

a variety of views on what these characteristics would be, if we a variety variety variety variety variety variety variety variety variety variety variety of views on what these characteristics characteristics characteristics characteristics characteristics characteristics characteristics characteristics characteristics characteristics characteristics would be, if we 

refer to Peter Senge, a noted authority on this matter, they would refer to Peter Senge, a noted authority authority authority authority authority authority authority authority authority authority authority on this matter, they would 

be: 

1. Systems thinking

2. Personal mastery

3. Mental models 

4. Shared vision

5. Team learning Team learning

According to Senge, these characteristics of a learning organi- According According According According According According According According According According According According to Senge, these characteristics characteristics characteristics characteristics characteristics characteristics characteristics characteristics characteristics characteristics characteristics characteristics of a learning learning learning learning learning learning learning learning learning learning learning learning organization, taken together, increase the capacity for adaptation and zation, zation, zation, zation, zation, zation, zation, zation, zation, zation, zation, taken together together together together together together together together together together together, increase increase increase increase increase increase increase increase increase increase increase the capacity capacity capacity capacity capacity capacity capacity capacity capacity capacity capacity for adaptation adaptation adaptation adaptation adaptation adaptation adaptation adaptation adaptation adaptation adaptation and 

change. The Diaz Team recognizes that none of this Reportʼs change. change. change. change. change. change. change. change. change. change. change. change. The Diaz Team recognizes recognizes recognizes recognizes recognizes recognizes recognizes recognizes recognizes recognizes recognizes recognizes that none of this Reportʼ Reportʼ Reportʼ Reportʼ Reportʼ Reportʼ Reportʼ Reportʼ Reportʼ Reportʼ Reportʼ Reportʼs 

discussion or recommendations address Learning in terms of discussion discussion discussion discussion discussion discussion discussion discussion discussion discussion discussion or recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations address address address address address address address address address address address Learning Learning Learning Learning Learning Learning Learning Learning Learning Learning Learning in terms of 

“changes in behavior” (per the defi nition of Learning) or the “changes “changes “changes “changes “changes “changes “changes “changes “changes “changes “changes “changes in behavior” behavior” behavior” behavior” behavior” behavior” behavior” behavior” behavior” behavior” behavior” behavior” (per the definition of Learning) Learning) Learning) Learning) Learning) Learning) Learning) Learning) Learning) Learning) Learning) Learning) or the 

ability to adapt and change, per Sengeʼs Learning Organization. ability ability ability ability ability ability ability ability ability ability ability to adapt and change, change, change, change, change, change, change, change, change, change, change, per Sengeʼs Learning Learning Learning Learning Learning Learning Learning Learning Learning Learning Learning Organization. ganization. ganization. ganization. ganization. ganization. ganization. ganization. ganization. ganization. ganization. 

However, learning by its very nature is not tied to one NASA However However However However However However However However However However However However, learning learning learning learning learning learning learning learning learning learning learning learning by its very nature is not tied to one NASA

program. Therefore, learning can have the widest applicability program. program. program. program. program. program. program. program. program. program. program. Therefore, Therefore, Therefore, Therefore, Therefore, Therefore, Therefore, Therefore, Therefore, Therefore, Therefore, learning learning learning learning learning learning learning learning learning learning learning can have the widest applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability 

across NASA. Aside from the obvious lesson to not repeat his- across NASA. Aside from the obvious obvious obvious obvious obvious obvious obvious obvious obvious obvious obvious lesson to not repeat history by failing to learn from it, the CAIB provided NASA with tory by failing failing failing failing failing failing failing failing failing failing failing failing to learn from it, the CAIB provided provided provided provided provided provided provided provided provided provided provided provided NASA with 

a number of recommendations and fi ndings that could help it a number of recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations and findings that could help it 

achieve the benefi cial traits of a learning organization. achieve the beneficial traits of a learning organization.

4.2 CATEGORY ATEGORY R-O-F S R-O-F SUMMARY

Overall there was one recommendation, no observations, and Overall Overall Overall Overall Overall Overall Overall Overall Overall Overall Overall there was one recommendation, recommendation, recommendation, recommendation, recommendation, recommendation, recommendation, recommendation, recommendation, recommendation, recommendation, no observations, observations, observations, observations, observations, observations, observations, observations, observations, observations, observations, and 

four fi ndings that the Diaz Team determined had broad NASA four findings that the Diaz Team determined determined determined determined determined determined determined determined determined determined determined had broad NASA

applicability to the Learning category. Table 13 shows these fi ve applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability to the Learning Learning Learning Learning Learning Learning Learning Learning Learning Learning Learning category category category category category category category category category category category. Table 13 shows these five 

R-O-Fs in brief summary statement form, along with brief dis- R-O-Fs in brief summary summary summary summary summary summary summary summary summary summary summary summary statement statement statement statement statement statement statement statement statement statement statement statement form, along with brief discussion points on NASA applicability. Two themes emerge from cussion cussion cussion cussion cussion cussion cussion cussion cussion cussion cussion points on NASA applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability. Two themes emerge from 

these discussion points as listed above.

4.3 DISCUSSION ISCUSSION

While there was only one CAIB recommendation that could While there was only one CAIB recommendation recommendation recommendation recommendation recommendation recommendation recommendation recommendation recommendation recommendation recommendation that could 

broadly apply to learning within NASA, inputs from individu- broadly broadly broadly broadly broadly broadly broadly broadly broadly broadly broadly broadly apply to learning learning learning learning learning learning learning learning learning learning learning learning within NASA, inputs from individu- individu- individu- individu- individu- individu- individu- individu- individu- individu- individu- individuals in the NASA workforce during Safety and Mission Success als in the NASA workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce during Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Success Success Success Success Success Success Success Success Success Success Success 

Week, as well as lessons from NASA mission successes and Week, as well as lessons lessons lessons lessons lessons lessons lessons lessons lessons lessons from NASA mission mission mission mission mission mission mission mission mission mission successes successes successes successes successes successes successes successes successes successes and 

failures, provide potential strategies to improve the NASA learn- failures, failures, failures, failures, failures, failures, failures, failures, failures, failures, failures, provide provide provide provide provide provide provide provide provide provide provide potential potential potential potential potential potential potential potential potential potential potential strategies strategies strategies strategies strategies strategies strategies strategies strategies strategies strategies to improve improve improve improve improve improve improve improve improve improve improve the NASA learning culture. The Diaz Teamʼs NASA-wide actions resulting from ing culture. culture. culture. culture. culture. culture. culture. culture. culture. culture. The Diaz Teamʼs NASA-wide NASA-wide NASA-wide NASA-wide NASA-wide NASA-wide NASA-wide NASA-wide NASA-wide NASA-wide actions actions actions actions actions actions actions actions actions actions resulting resulting resulting resulting resulting resulting resulting resulting resulting resulting from 

these R-O-Fs require that NASA address training and learning these R-O-Fs require require require require require require require require require require require that NASA address address address address address address address address address address address training training training training training training training training training training training and learning learning learning learning learning learning learning learning learning learning learning 

technology on a comprehensive basis. 

It is recognized there are efforts underway in NASA to address It is recognized recognized recognized recognized recognized recognized recognized recognized recognized recognized there are efforts underway underway underway underway underway underway underway underway underway underway in NASA to address address address address address address address address address address 

knowledge capture, management, and dissemination. These ac- knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge capture, capture, capture, capture, capture, capture, capture, capture, capture, capture, capture, management, management, management, management, management, management, management, management, management, management, management, and dissemination. dissemination. dissemination. dissemination. dissemination. dissemination. dissemination. dissemination. dissemination. dissemination. dissemination. These actions are in response to the concern for the impending retirement tions are in response response response response response response response response response response to the concern concern concern concern concern concern concern concern concern concern for the impending impending impending impending impending impending impending impending impending impending retirement retirement retirement retirement retirement retirement retirement retirement retirement retirement 

of a large segment of the NASA workforce. The best recent of a large segment segment segment segment segment segment segment segment segment segment of the NASA workforce. workforce. workforce. workforce. workforce. workforce. workforce. workforce. workforce. workforce. The best recent 

example has been the Corporate hiring strategy which has pro- example example example example example example example example example example example has been the Corporate Corporate Corporate Corporate Corporate Corporate Corporate Corporate Corporate Corporate Corporate hiring strategy strategy strategy strategy strategy strategy strategy strategy strategy strategy strategy which has promoted the use of existing Agency authority to hire freshouts. This moted the use of existing existing existing existing existing existing existing existing existing existing Agency authority authority authority authority authority authority authority authority authority authority to hire freshouts. freshouts. freshouts. freshouts. freshouts. freshouts. freshouts. freshouts. freshouts. freshouts. This 

action will help in assuring that critical skills are replaced early action will help in assuring assuring assuring assuring assuring assuring assuring assuring assuring assuring assuring that critical critical critical critical critical critical critical critical critical critical critical skills are replaced replaced replaced replaced replaced replaced replaced replaced replaced replaced replaced early 

enough to assure overlap in some areas where retirements are enough to assure overlap overlap overlap overlap overlap overlap overlap overlap overlap overlap in some areas where retirements retirements retirements retirements retirements retirements retirements retirements retirements retirements are 

anticipated. But more needs to be done to understand what the anticipated. anticipated. anticipated. anticipated. anticipated. anticipated. anticipated. anticipated. anticipated. anticipated. anticipated. But more needs to be done to understand understand understand understand understand understand understand understand understand understand understand what the 

knowledge architecture in NASA is so that steps can be taken to knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge architecture architecture architecture architecture architecture architecture architecture architecture architecture architecture in NASA is so that steps can be taken to 

preserve it. 

In addition, comprehensive and systematic emergency response In addition, addition, addition, addition, addition, addition, addition, addition, addition, addition, comprehensive comprehensive comprehensive comprehensive comprehensive comprehensive comprehensive comprehensive comprehensive comprehensive and systematic systematic systematic systematic systematic systematic systematic systematic systematic systematic emergency response response response response response response response response response response 

training simulating the work environment, as well as hands-on training training training training training training training training training training training simulating simulating simulating simulating simulating simulating simulating simulating simulating simulating simulating the work environment, environment, environment, environment, environment, environment, environment, environment, environment, environment, environment, as well as hands-on hands-on hands-on hands-on hands-on hands-on hands-on hands-on hands-on hands-on hands-on 

experience, are critical to creating a learning organization. NASA experience, experience, experience, experience, experience, experience, experience, experience, experience, experience, are critical critical critical critical critical critical critical critical critical critical to creating creating creating creating creating creating creating creating creating creating a learning learning learning learning learning learning learning learning learning learning organization. ganization. ganization. ganization. ganization. ganization. ganization. ganization. ganization. ganization. NASA

personnel need to achieve a high level of technical and manage- personnel personnel personnel personnel personnel personnel personnel personnel personnel personnel personnel need to achieve achieve achieve achieve achieve achieve achieve achieve achieve achieve achieve a high level of technical technical technical technical technical technical technical technical technical technical technical and manage- manage- manage- manage- manage- manage- manage- manage- manage- manage- managerial competency along with a high state of readiness to deal with rial competency competency competency competency competency competency competency competency competency competency along with a high state of readiness readiness readiness readiness readiness readiness readiness readiness readiness readiness to deal with 

the research, developmental, and operational challenges inherent the research, research, research, research, research, research, research, research, research, research, research, developmental, developmental, developmental, developmental, developmental, developmental, developmental, developmental, developmental, developmental, developmental, and operational operational operational operational operational operational operational operational operational operational operational challenges challenges challenges challenges challenges challenges challenges challenges challenges challenges challenges inherent inherent inherent inherent inherent inherent inherent inherent inherent inherent inherent 

in the aerospace systems they manage and operate. In concert, in the aerospace aerospace aerospace aerospace aerospace aerospace aerospace aerospace aerospace aerospace systems systems systems systems systems systems systems systems systems systems they manage and operate. operate. operate. operate. operate. operate. operate. operate. operate. operate. In concert, concert, concert, concert, concert, concert, concert, concert, concert, concert, 

the technical tools, information systems, and knowledge reposi- the technical technical technical technical technical technical technical technical technical technical tools, information information information information information information information information information information systems, systems, systems, systems, systems, systems, systems, systems, systems, systems, and knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge reposi- reposi- reposi- reposi- reposi- reposi- reposi- reposi- reposi- repositories of the Agency must be up to date and readily available to tories of the Agency must be up to date and readily readily readily readily readily readily readily readily readily readily readily available available available available available available available available available available available to 

be used by personnel across the Agency. Supervisors must also be used by personnel personnel personnel personnel personnel personnel personnel personnel personnel personnel across the Agency. Supervisors Supervisors Supervisors Supervisors Supervisors Supervisors Supervisors Supervisors Supervisors Supervisors must also 

take an active leadership role in fostering professional develop- take an active leadership leadership leadership leadership leadership leadership leadership leadership leadership leadership leadership role in fostering fostering fostering fostering fostering fostering fostering fostering fostering fostering fostering professional professional professional professional professional professional professional professional professional professional professional develop- develop- develop- develop- develop- develop- develop- develop- develop- develop- development of their subordinates and ensure that necessary technical ment of their subordinates subordinates subordinates subordinates subordinates subordinates subordinates subordinates subordinates subordinates and ensure that necessary necessary necessary necessary necessary necessary necessary necessary necessary necessary technical technical technical technical technical technical technical technical technical technical 

and leadership skills are developed in the workforce.

For Shuttle mission operations, the CAIB had noted that NASA For Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle mission mission mission mission mission mission mission mission mission mission mission operations, operations, operations, operations, operations, operations, operations, operations, operations, operations, operations, the CAIB had noted that NASA

did not always “train like you operate” and “operate like you did not always “train like you operate” operate” operate” operate” operate” operate” operate” operate” operate” operate” and “operate “operate “operate “operate “operate “operate “operate “operate “operate “operate like you 

train.” This same maxim can be applied to training for NASA train.” train.” train.” train.” train.” train.” train.” train.” train.” train.” This same maxim can be applied applied applied applied applied applied applied applied applied applied to training training training training training training training training training training for NASA

personnel across all operational programs. Training should em- personnel personnel personnel personnel personnel personnel personnel personnel personnel personnel personnel across all operational operational operational operational operational operational operational operational operational operational operational programs. programs. programs. programs. programs. programs. programs. programs. programs. programs. programs. Training raining raining raining raining raining raining raining raining raining raining should embody how the organization will operate its missions, and operate body how the organization ganization ganization ganization ganization ganization ganization ganization ganization ganization will operate operate operate operate operate operate operate operate operate operate its missions, missions, missions, missions, missions, missions, missions, missions, missions, missions, and operate operate operate operate operate operate operate operate operate operate 

their missions the way they trained. Safety and Mission Success their missions missions missions missions missions missions missions missions missions missions missions the way they trained. trained. trained. trained. trained. trained. trained. trained. trained. trained. trained. Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Success Success Success Success Success Success Success Success Success Success Success 

Week responses validated this need with input that the Agency Week responses responses responses responses responses responses responses responses responses responses validated validated validated validated validated validated validated validated validated validated this need with input that the Agency 

must devote greater resources, particularly training resources to must devote greater greater greater greater greater greater greater greater greater greater greater resources, resources, resources, resources, resources, resources, resources, resources, resources, resources, resources, particularly particularly particularly particularly particularly particularly particularly particularly particularly particularly particularly training training training training training training training training training training training resources resources resources resources resources resources resources resources resources resources resources to 

facilitate learning. NASA must fi rst examine best practices for facilitate facilitate facilitate facilitate facilitate facilitate facilitate facilitate facilitate facilitate learning. learning. learning. learning. learning. learning. learning. learning. learning. learning. NASA must first examine examine examine examine examine examine examine examine examine examine best practices practices practices practices practices practices practices practices practices practices for 

contingency, emergency, and operational procedures and train- contingency contingency contingency contingency contingency contingency contingency contingency contingency contingency, emergency, and operational operational operational operational operational operational operational operational operational operational procedures procedures procedures procedures procedures procedures procedures procedures procedures procedures and training, and then make the appropriate comprehensive changes for ing, and then make the appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate comprehensive comprehensive comprehensive comprehensive comprehensive comprehensive comprehensive comprehensive comprehensive comprehensive changes changes changes changes changes changes changes changes changes changes for 

safety and mission success.

The fi rst common aspect is the appropriate use of tools, da- The first common aspect is the appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate use of tools, databases, and simulation and modeling programs by operating tabases, tabases, tabases, tabases, tabases, tabases, tabases, tabases, tabases, tabases, tabases, and simulation simulation simulation simulation simulation simulation simulation simulation simulation simulation simulation and modeling modeling modeling modeling modeling modeling modeling modeling modeling modeling modeling programs programs programs programs programs programs programs programs programs programs programs by operating operating operating operating operating operating operating operating operating operating operating 

personnel. Of particular importance is training on their relevance personnel. personnel. personnel. personnel. personnel. personnel. personnel. personnel. personnel. personnel. Of particular particular particular particular particular particular particular particular particular particular importance importance importance importance importance importance importance importance importance importance is training training training training training training training training training training on their relevance relevance relevance relevance relevance relevance relevance relevance relevance relevance 

and the environments in which they apply. The improper use of and the environments environments environments environments environments environments environments environments environments environments environments in which they apply. The improper improper improper improper improper improper improper improper improper improper improper use of 

the CRATER program in assessing debris damage to the CRATER program program program program program program program program in assessing assessing assessing assessing assessing assessing assessing assessing debris damage to Columbia

is a prime example of the need to fully understand how to use is a prime example example example example example example example example example example of the need to fully understand understand understand understand understand understand understand understand understand understand how to use 

modeling tools correctly. In addition, training on the history and modeling modeling modeling modeling modeling modeling modeling modeling modeling modeling modeling tools correctly correctly correctly correctly correctly correctly correctly correctly correctly correctly correctly. In addition, addition, addition, addition, addition, addition, addition, addition, addition, addition, addition, training training training training training training training training training training training on the history history history history history history history history history history history and 

the underlying development of these tools is critical. The CAIB the underlying underlying underlying underlying underlying underlying underlying underlying underlying underlying development development development development development development development development development development of these tools is critical. critical. critical. critical. critical. critical. critical. critical. critical. critical. The CAIB 

4.0 LEARNING

CAIB Report Chapter 7, p192:

The Board concludes that NASA’s current organization does not provide effective checks-and-balances, does not 

have an independent safety program, and has not demonstrated the characteristics of a learning organization. 
2 7
2 8

Report noted that an “inexperienced team, using a mathematical Report noted that an “inexperienced “inexperienced “inexperienced “inexperienced “inexperienced “inexperienced “inexperienced “inexperienced “inexperienced “inexperienced “inexperienced team, using a mathematical mathematical mathematical mathematical mathematical mathematical mathematical mathematical mathematical mathematical mathematical 

tool that was not designed to assess an impact of this estimated tool that was not designed designed designed designed designed designed designed designed designed designed designed to assess an impact of this estimated estimated estimated estimated estimated estimated estimated estimated estimated estimated estimated 

size, performed the analysis of the potential effect of the debris size, performed performed performed performed performed performed performed performed performed performed performed performed the analysis analysis analysis analysis analysis analysis analysis analysis analysis analysis analysis analysis of the potential potential potential potential potential potential potential potential potential potential potential potential effect of the debris 

impact.” 

The feedback from Safety and Mission Success Week reinforced The feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback from Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Success Success Success Success Success Success Success Success Success Success Success Week reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced 

the Diaz Team assessment: the Diaz Team assessment:

» Mandate that current and new employees moving into 

management positions attend a lecture (sponsored by 

NASA) outlining historical lessons learned by NASA NASA) outlining historical lessons learned by NASA

and comparable agencies. This lecture should be at and comparable agencies. This lecture should be at 

least one day long and should cover lessons learned 

in several disasters (Challenger, Columbia, Apollo 1, 

USS Thresher USS Thresher) and close calls (i.e. STS-93 and Apollo 

13).

» NASA should routinely run mock mishap investiga- NASA should routinely run mock mishap investigations to root out its process, product, and programmatic tions to root out its process, process, process, process, process, process, process, process, process, product, product, product, product, product, product, product, product, product, and programmatic programmatic programmatic programmatic programmatic programmatic programmatic programmatic programmatic 

weaknesses before a mishap actually happens.

» NASA does not effectively transfer knowledge. NASA NASA does not effectively transfer knowledge. NASA

can signifi cantly improve our knowledge management can significantly improve our knowledge management 

culture with lessons learned processes, trend analyses, 

transferring expert knowledge from people to systems, 

and portals that share information.

» NASA should employ a more rigorous/disciplined ac- NASA should employ a more rigorous/disciplined acceptance testing & checkout procedure prior to placing 

any system (hardware or software) in operation. The any system (hardware or software) in operation. The 

requirements and results should be kept in a database 

with an independent group auditing input.

Knowledge management is a key element in creating a learning Knowledge Knowledge Knowledge Knowledge Knowledge Knowledge Knowledge Knowledge Knowledge Knowledge Knowledge management management management management management management management management management management management is a key element element element element element element element element element element element in creating creating creating creating creating creating creating creating creating creating creating a learning learning learning learning learning learning learning learning learning learning learning 

environment so the CAIB Report lessons are indeed not lost. The environment environment environment environment environment environment environment environment environment environment environment environment so the CAIB Report lessons lessons lessons lessons lessons lessons lessons lessons lessons lessons lessons lessons are indeed not lost. The 

CAIB Report noted “ideally, the Lessons Learned Information CAIB Report noted “ideally “ideally “ideally “ideally “ideally “ideally “ideally “ideally “ideally “ideally “ideally, the Lessons Lessons Lessons Lessons Lessons Lessons Lessons Lessons Lessons Lessons Lessons Learned Learned Learned Learned Learned Learned Learned Learned Learned Learned Learned Information Information Information Information Information Information Information Information Information Information Information 

System should support overall program management and engi- System should support support support support support support support support support support support overall overall overall overall overall overall overall overall overall overall overall program program program program program program program program program program program management management management management management management management management management management management and engineering functions and provide an historical experience base.” neering neering neering neering neering neering neering neering neering neering neering neering functions functions functions functions functions functions functions functions functions functions functions functions and provide provide provide provide provide provide provide provide provide provide provide provide an historical historical historical historical historical historical historical historical historical historical historical historical experience experience experience experience experience experience experience experience experience experience experience experience base.” 

When Shuttle Program Management declined to have the crew When Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Program Program Program Program Program Program Program Program Program Program Program Management Management Management Management Management Management Management Management Management Management Management declined declined declined declined declined declined declined declined declined declined declined to have the crew 

inspect the inspect the Columbia for damage while on orbit, when it did so for damage while on orbit, when it did so 

for a previous debris impact mission, this illustrated to the Board for a previous previous previous previous previous previous previous previous previous previous previous debris impact mission, mission, mission, mission, mission, mission, mission, mission, mission, mission, mission, this illustrated illustrated illustrated illustrated illustrated illustrated illustrated illustrated illustrated illustrated illustrated to the Board 

a lack of “institutional memory” that supported the Boardʼs claim a lack of “institutional “institutional “institutional “institutional “institutional “institutional “institutional “institutional “institutional “institutional “institutional “institutional memory” memory” memory” memory” memory” memory” memory” memory” memory” memory” memory” memory” that supported supported supported supported supported supported supported supported supported supported supported supported the Boardʼs claim 

NASA is not managing its knowledge resources. NASA is not managing its knowledge resources.

The Safety and Mission Success Week provided valuable insight The Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Success Success Success Success Success Success Success Success Success Success Success Week provided provided provided provided provided provided provided provided provided provided provided valuable valuable valuable valuable valuable valuable valuable valuable valuable valuable valuable insight insight insight insight insight insight insight insight insight insight insight 

in singling out knowledge management weakness along with a in singling singling singling singling singling singling singling singling singling singling singling out knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge management management management management management management management management management management management weakness weakness weakness weakness weakness weakness weakness weakness weakness weakness weakness along with a 

suggested cure. Responses suggested NASA does not effectively suggested suggested suggested suggested suggested suggested suggested suggested suggested suggested suggested suggested cure. Responses Responses Responses Responses Responses Responses Responses Responses Responses Responses Responses Responses suggested suggested suggested suggested suggested suggested suggested suggested suggested suggested suggested suggested NASA does not effectively fectively fectively fectively fectively fectively fectively fectively fectively fectively fectively fectively 

transfer knowledge, and can signifi cantly improve the knowl- transfer transfer transfer transfer transfer transfer transfer transfer transfer transfer transfer knowledge, knowledge, knowledge, knowledge, knowledge, knowledge, knowledge, knowledge, knowledge, knowledge, knowledge, and can signifi signicantly improve improve improve improve improve improve improve improve improve improve improve the knowledge management culture with lessons learned processes, trend edge management management management management management management management management management management management management culture culture culture culture culture culture culture culture culture culture culture culture with lessons lessons lessons lessons lessons lessons lessons lessons lessons lessons lessons lessons learned learned learned learned learned learned learned learned learned learned learned learned processes, processes, processes, processes, processes, processes, processes, processes, processes, processes, processes, processes, trend 

analyses, transferring expert knowledge from people to systems, analyses, analyses, analyses, analyses, analyses, analyses, analyses, analyses, analyses, analyses, analyses, transferring transferring transferring transferring transferring transferring transferring transferring transferring transferring transferring expert knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge from people to systems, systems, systems, systems, systems, systems, systems, systems, systems, systems, systems, 

and portals that share information. This Safety and Mission Suc- and portals portals portals portals portals portals portals portals portals portals portals portals that share information. information. information. information. information. information. information. information. information. information. information. information. This Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Success feedback provides a focal point for the training and methods cess feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback provides provides provides provides provides provides provides provides provides provides a focal point for the training training training training training training training training training training and methods methods methods methods methods methods methods methods methods methods 

necessary for an effective learning environment. necessary for an effective learning environment. 

Another fundamental aspect of learning in NASA is training in Another Another Another Another Another Another Another Another Another Another fundamental fundamental fundamental fundamental fundamental fundamental fundamental fundamental fundamental fundamental aspect of learning learning learning learning learning learning learning learning learning learning in NASA is training training training training training training training training training training in 

contingency and emergency procedures, which NASA should contingency contingency contingency contingency contingency contingency contingency contingency contingency contingency contingency and emergency procedures, procedures, procedures, procedures, procedures, procedures, procedures, procedures, procedures, procedures, procedures, which NASA should 

conduct on all programs. Included in this aspect of an effective conduct conduct conduct conduct conduct conduct conduct conduct conduct conduct on all programs. programs. programs. programs. programs. programs. programs. programs. programs. programs. Included Included Included Included Included Included Included Included Included Included in this aspect of an effective fective fective fective fective fective fective fective fective fective 

and rigorous training program are:

1. Situational awareness;

2. Experiencing problems without known outcomes; and

3. Simulating a stressful environment for decision-making.

NASA can explore personnel training and learning through a NASA can explore explore explore explore explore explore explore explore explore explore explore personnel personnel personnel personnel personnel personnel personnel personnel personnel personnel personnel training training training training training training training training training training training and learning learning learning learning learning learning learning learning learning learning learning through through through through through through through through through through through a 

variety of methods. More on-the-job training through appren- variety variety variety variety variety variety variety variety variety variety of methods. methods. methods. methods. methods. methods. methods. methods. methods. methods. More on-the-job on-the-job on-the-job on-the-job on-the-job on-the-job on-the-job on-the-job on-the-job on-the-job training training training training training training training training training training through through through through through through through through through through appren- appren- appren- appren- appren- appren- appren- appren- appren- apprenticeship programs and hands-on work can be emphasized for ticeship ticeship ticeship ticeship ticeship ticeship ticeship ticeship ticeship ticeship ticeship programs programs programs programs programs programs programs programs programs programs programs and hands-on hands-on hands-on hands-on hands-on hands-on hands-on hands-on hands-on hands-on hands-on work can be emphasized emphasized emphasized emphasized emphasized emphasized emphasized emphasized emphasized emphasized emphasized for 

critical skills being lost at the Centers. NASA-wide information critical critical critical critical critical critical critical critical critical critical skills being lost at the Centers. Centers. Centers. Centers. Centers. Centers. Centers. Centers. Centers. Centers. NASA-wide NASA-wide NASA-wide NASA-wide NASA-wide NASA-wide NASA-wide NASA-wide NASA-wide NASA-wide information information information information information information information information information information 

systems utilizing the Web can be a powerful method for dissemi- systems systems systems systems systems systems systems systems systems systems utilizing utilizing utilizing utilizing utilizing utilizing utilizing utilizing utilizing utilizing the Web can be a powerful powerful powerful powerful powerful powerful powerful powerful powerful powerful method for dissemi- dissemi- dissemi- dissemi- dissemi- dissemi- dissemi- dissemi- dissemi- dissemination of knowledge throughout the Agency. The CAIB noted nation of knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge throughout throughout throughout throughout throughout throughout throughout throughout throughout throughout throughout the Agency. The CAIB noted 

the existence of multiple databases without any convenient way the existence existence existence existence existence existence existence existence existence existence of multiple multiple multiple multiple multiple multiple multiple multiple multiple multiple databases databases databases databases databases databases databases databases databases databases without without without without without without without without without without any convenient convenient convenient convenient convenient convenient convenient convenient convenient convenient way 

to integrate them. The consolidation and linkage of information to integrate integrate integrate integrate integrate integrate integrate integrate integrate integrate integrate them. The consolidation consolidation consolidation consolidation consolidation consolidation consolidation consolidation consolidation consolidation consolidation and linkage linkage linkage linkage linkage linkage linkage linkage linkage linkage linkage of information information information information information information information information information information information 

systems to provide effective collaboration and information shar- systems systems systems systems systems systems systems systems systems systems to provide provide provide provide provide provide provide provide provide provide effective fective fective fective fective fective fective fective fective fective collaboration collaboration collaboration collaboration collaboration collaboration collaboration collaboration collaboration collaboration and information information information information information information information information information information sharing is important to NASA becoming a learning organization. ing is important to NASA becoming a learning organization. 

As part of career development and embracing life-long learning As part of career development development development development development development development development development development and embracing embracing embracing embracing embracing embracing embracing embracing embracing embracing life-long life-long life-long life-long life-long life-long life-long life-long life-long life-long learning learning learning learning learning learning learning learning learning learning 

as a method of creating a true learning organization, personnel as a method of creating creating creating creating creating creating creating creating creating creating a true learning learning learning learning learning learning learning learning learning learning organization, ganization, ganization, ganization, ganization, ganization, ganization, ganization, ganization, ganization, personnel personnel personnel personnel personnel personnel personnel personnel personnel personnel 

should be encouraged to improve their certifi cation levels and should be encouraged encouraged encouraged encouraged encouraged encouraged encouraged encouraged encouraged encouraged to improve improve improve improve improve improve improve improve improve improve their certifi certication levels and 

attend specialized training and development programs. These attend specialized specialized specialized specialized specialized specialized specialized specialized specialized specialized specialized training training training training training training training training training training training and development development development development development development development development development development development programs. programs. programs. programs. programs. programs. programs. programs. programs. programs. programs. These 

are key to the Agency being technologically current on the latest are key to the Agency being technologically technologically technologically technologically technologically technologically technologically technologically technologically technologically current current current current current current current current current current on the latest 

technical and management methods. Role-playing, simulations, technical technical technical technical technical technical technical technical technical technical technical and management management management management management management management management management management management methods. methods. methods. methods. methods. methods. methods. methods. methods. methods. methods. Role-playing, Role-playing, Role-playing, Role-playing, Role-playing, Role-playing, Role-playing, Role-playing, Role-playing, Role-playing, Role-playing, simulations, simulations, simulations, simulations, simulations, simulations, simulations, simulations, simulations, simulations, simulations, 

and case study development and utilization on a comprehensive and case study development development development development development development development development development development and utilization utilization utilization utilization utilization utilization utilization utilization utilization utilization on a comprehensive comprehensive comprehensive comprehensive comprehensive comprehensive comprehensive comprehensive comprehensive comprehensive 

basis can also contribute to creating a learning environment. basis can also contribute contribute contribute contribute contribute contribute contribute contribute contribute contribute contribute to creating creating creating creating creating creating creating creating creating creating creating a learning learning learning learning learning learning learning learning learning learning learning environment. environment. environment. environment. environment. environment. environment. environment. environment. environment. environment. 

Leaders and supervisors are responsible for ensuring that em- Leaders Leaders Leaders Leaders Leaders Leaders Leaders Leaders Leaders Leaders and supervisors supervisors supervisors supervisors supervisors supervisors supervisors supervisors supervisors supervisors are responsible responsible responsible responsible responsible responsible responsible responsible responsible responsible for ensuring ensuring ensuring ensuring ensuring ensuring ensuring ensuring ensuring ensuring that employees learn needed skills and develop capabilities to perform ployees ployees ployees ployees ployees ployees ployees ployees ployees ployees learn needed skills and develop develop develop develop develop develop develop develop develop develop capabilities capabilities capabilities capabilities capabilities capabilities capabilities capabilities capabilities capabilities to perform perform perform perform perform perform perform perform perform perform 

future missions, as well as mentoring them. 

Many of these methods and activities are already in place across Many of these methods methods methods methods methods methods methods methods methods methods methods and activities activities activities activities activities activities activities activities activities activities activities are already already already already already already already already already already already in place across 

the Agency. The next step is to comprehensively assess what the Agency. The next step is to comprehensively comprehensively comprehensively comprehensively comprehensively comprehensively comprehensively comprehensively comprehensively comprehensively assess what 

needs to be improved. NASA leadership must make learning needs to be improved. improved. improved. improved. improved. improved. improved. improved. improved. improved. improved. NASA leadership leadership leadership leadership leadership leadership leadership leadership leadership leadership leadership must make learning learning learning learning learning learning learning learning learning learning learning 

a priority to facilitate the workforce acquiring and retaining a priority priority priority priority priority priority priority priority priority priority to facilitate facilitate facilitate facilitate facilitate facilitate facilitate facilitate facilitate facilitate the workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce acquiring acquiring acquiring acquiring acquiring acquiring acquiring acquiring acquiring acquiring and retaining retaining retaining retaining retaining retaining retaining retaining retaining retaining 

needed skills and competencies, thereby contributing to success- needed skills and competencies, competencies, competencies, competencies, competencies, competencies, competencies, competencies, competencies, competencies, competencies, thereby thereby thereby thereby thereby thereby thereby thereby thereby thereby thereby contributing contributing contributing contributing contributing contributing contributing contributing contributing contributing contributing to success- success- success- success- success- success- success- success- success- success- successful mission accomplishment. 

In addition to the actions in the Diaz Team Matrix that address In addition addition addition addition addition addition addition addition addition addition addition to the actions actions actions actions actions actions actions actions actions actions actions in the Diaz Team Matrix that address address address address address address address address address address address 

each R-O-F, the Diaz Team has one goal addressing the Learning each R-O-F, the Diaz Team has one goal addressing addressing addressing addressing addressing addressing addressing addressing addressing addressing the Learning Learning Learning Learning Learning Learning Learning Learning Learning Learning 

category, as shown in Table 12. category, as shown in Table 12.

Table 12. The Diaz Team developed one goal for Learning.

Learning – Diaz Team Goal

The Agency should identify an appropriate approach for the future development of a knowledge management system and 

infrastructure to assure knowledge retention and lessons learned.
2 9

Table 13. The Diaz Team determined that one Recommendation and four Findings could be included in the Learning Category resulting in three actions.

Diaz 

Team # CAIB # CAIB Report Recommendations and Pertinent Factors Diaz Summary Discussion Diaz Action # Responsible

R20 R6.3-1 Expanded training program for Mission 

Management Team

All programs need robust training and 

simulation 7 AE

F96 F6.3-23 Little discussion of analysis, assumptions, 

issues Managers need to base decisions on facts 7 AE

F114 F7.4-9 Information databases marginally effective 

decision tools

Need for assessing program management 

support tools 38 AE

F115 F7.4-10 SR&QA do not use the Lessons Learned 

Info System

Case studies and training for lessons 

learned needed 38 AE

F116 F7.4-11 Multiple databases without a convenient way 

to integrate

Database commonality and real-time access 

necessary

39 AE
3 0

Communication did not fl ow effectively. 

Agency-wide Themes

• Anomalies should be considered problems until 

proven otherwise.

• Responsibility, authority, and accountability must 

be clearly understood and communicated.

• Communications need to fl ow both up and down 

the chain of command.

• Diverse viewpoints must be fostered and minority views considered.

• Communication practices must be validated and 

tested to ensure effective communication across 

NASA.

5.1 INTRODUCTION NTRODUCTION

The Diaz Team Communication category addresses defi ciencies The Diaz Team Communication Communication Communication Communication Communication Communication Communication Communication Communication Communication Communication Communication category category category category category category category category category category category category addresses addresses addresses addresses addresses addresses addresses addresses addresses addresses addresses addresses deficiencies ciencies ciencies ciencies ciencies ciencies ciencies ciencies ciencies ciencies ciencies ciencies 

in NASAʼs organizational communication. This category inter- in NASAʼs organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational communication. communication. communication. communication. communication. communication. communication. communication. communication. communication. communication. This category category category category category category category category category category category interrelates with the other categories focusing on NASAʼs leadership relates relates relates relates relates relates relates relates relates relates relates relates with the other categories categories categories categories categories categories categories categories categories categories categories categories focusing focusing focusing focusing focusing focusing focusing focusing focusing focusing focusing focusing on NASAʼs leadership leadership leadership leadership leadership leadership leadership leadership leadership leadership leadership leadership 

behavior, organizational structures, and management practices. behavior behavior behavior behavior behavior behavior behavior behavior behavior behavior behavior, organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational structures, structures, structures, structures, structures, structures, structures, structures, structures, structures, structures, and management management management management management management management management management management management practices. practices. practices. practices. practices. practices. practices. practices. practices. practices. practices. 

Collectively, weaknesses in these areas may contribute to the de- Collectively Collectively Collectively Collectively Collectively Collectively Collectively Collectively Collectively Collectively Collectively Collectively, weaknesses weaknesses weaknesses weaknesses weaknesses weaknesses weaknesses weaknesses weaknesses weaknesses weaknesses weaknesses in these areas may contribute contribute contribute contribute contribute contribute contribute contribute contribute contribute contribute contribute to the development of communication barriers across Centers and within velopment velopment velopment velopment velopment velopment velopment velopment velopment velopment velopment of communication communication communication communication communication communication communication communication communication communication communication barriers barriers barriers barriers barriers barriers barriers barriers barriers barriers barriers across Centers Centers Centers Centers Centers Centers Centers Centers Centers Centers Centers and within 

programs. The CAIB came to several fi ndings regarding the ef- programs. programs. programs. programs. programs. programs. programs. programs. programs. programs. programs. The CAIB came to several several several several several several several several several several several findings regarding regarding regarding regarding regarding regarding regarding regarding regarding regarding regarding the effect of NASAʼs communication practices as contributing to the fect of NASAʼs communication communication communication communication communication communication communication communication communication communication communication communication practices practices practices practices practices practices practices practices practices practices practices practices as contributing contributing contributing contributing contributing contributing contributing contributing contributing contributing contributing contributing to the 

loss of loss of Columbia. Over time, NASA elements have evolved to . Over time, NASA elements elements elements elements elements elements elements elements have evolved evolved evolved evolved evolved evolved evolved evolved to 

a stove-piped hierarchy where specifi c individual accountability a stove-piped stove-piped stove-piped stove-piped stove-piped stove-piped stove-piped stove-piped stove-piped stove-piped stove-piped stove-piped hierarchy hierarchy hierarchy hierarchy hierarchy hierarchy hierarchy hierarchy hierarchy hierarchy hierarchy hierarchy where specifi specic individual individual individual individual individual individual individual individual individual individual individual individual accountability accountability accountability accountability accountability accountability accountability accountability accountability accountability accountability accountability 

may be lost, resulting in individuals not fully understanding their may be lost, resulting resulting resulting resulting resulting resulting resulting resulting resulting resulting resulting in individuals individuals individuals individuals individuals individuals individuals individuals individuals individuals individuals not fully understanding understanding understanding understanding understanding understanding understanding understanding understanding understanding understanding their 

roles, responsibilities, and vested authority. In reaction, informal roles, responsibilities, responsibilities, responsibilities, responsibilities, responsibilities, responsibilities, responsibilities, responsibilities, responsibilities, responsibilities, responsibilities, responsibilities, and vested authority authority authority authority authority authority authority authority authority authority authority authority. In reaction, reaction, reaction, reaction, reaction, reaction, reaction, reaction, reaction, reaction, reaction, reaction, informal informal informal informal informal informal informal informal informal informal informal informal 

networks and chains of command have formed that are organiza- networks networks networks networks networks networks networks networks networks networks networks and chains of command command command command command command command command command command command have formed that are organiza- ganiza- ganiza- ganiza- ganiza- ganiza- ganiza- ganiza- ganiza- ganiza- ganizationally dispersed and may inhibit the clear fl ow of information. tionally tionally tionally tionally tionally tionally tionally tionally tionally tionally tionally tionally dispersed dispersed dispersed dispersed dispersed dispersed dispersed dispersed dispersed dispersed dispersed dispersed and may inhibit inhibit inhibit inhibit inhibit inhibit inhibit inhibit inhibit inhibit inhibit inhibit the clear flow of information. information. information. information. information. information. information. information. information. information. information. information. 

Consequently, problems may manifest themselves in tension Consequently Consequently Consequently Consequently Consequently Consequently Consequently Consequently Consequently Consequently Consequently, problems problems problems problems problems problems problems problems problems problems problems may manifest manifest manifest manifest manifest manifest manifest manifest manifest manifest manifest themselves themselves themselves themselves themselves themselves themselves themselves themselves themselves themselves in tension tension tension tension tension tension tension tension tension tension tension 

between Center authority and Program management direction of between between between between between between between between between between between Center authority authority authority authority authority authority authority authority authority authority authority and Program Program Program Program Program Program Program Program Program Program Program management management management management management management management management management management management direction direction direction direction direction direction direction direction direction direction direction of 

multi-Center activities. 

5.2 CATEGORY ATEGORY R-O-F S R-O-F SUMMARY

Overall there were no recommendations, no observations, and Overall Overall Overall Overall Overall Overall Overall Overall Overall Overall Overall Overall there were no recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, no observations, observations, observations, observations, observations, observations, observations, observations, observations, observations, observations, observations, and 

fi ve fi ndings that the Diaz Team determined had broad NASA ap- five findings that the Diaz Team determined determined determined determined determined determined determined determined determined determined determined had broad NASA applicability to Communication. Table 15 shows the fi ve fi ndings in plicability plicability plicability plicability plicability plicability plicability plicability plicability plicability plicability to Communication. Communication. Communication. Communication. Communication. Communication. Communication. Communication. Communication. Communication. Communication. Table 15 shows the five findings in 

brief summary statement form, along with brief discussion points brief summary summary summary summary summary summary summary summary summary summary summary statement statement statement statement statement statement statement statement statement statement statement form, along with brief discussion discussion discussion discussion discussion discussion discussion discussion discussion discussion discussion points 

on NASA applicability. Five themes emerge from these discus- on NASA applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability. Five themes emerge from these discus- discus- discus- discus- discus- discus- discus- discus- discus- discus- discussion points as listed above.

5.3 DISCUSSION ISCUSSION

The fi ve fi ndings resulted in two actions for implementation. The five findings resulted resulted resulted resulted resulted resulted resulted resulted resulted resulted resulted resulted in two actions actions actions actions actions actions actions actions actions actions actions actions for implementation. implementation. implementation. implementation. implementation. implementation. implementation. implementation. implementation. implementation. implementation. implementation. 

When broadly applied, the two actions focus on developing When broadly broadly broadly broadly broadly broadly broadly broadly broadly broadly broadly applied, applied, applied, applied, applied, applied, applied, applied, applied, applied, applied, the two actions actions actions actions actions actions actions actions actions actions actions focus on developing developing developing developing developing developing developing developing developing developing developing 

a management and communication culture that is based on a management management management management management management management management management management management and communication communication communication communication communication communication communication communication communication communication communication culture culture culture culture culture culture culture culture culture culture culture that is based on 

adequate discourse for anomaly resolution, a clear process for adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate discourse discourse discourse discourse discourse discourse discourse discourse discourse discourse discourse discourse for anomaly anomaly anomaly anomaly anomaly anomaly anomaly anomaly anomaly anomaly anomaly anomaly resolution, resolution, resolution, resolution, resolution, resolution, resolution, resolution, resolution, resolution, resolution, resolution, a clear process process process process process process process process process process process process for 

chain of command and contingency communication, and the chain of command command command command command command command command command command command and contingency contingency contingency contingency contingency contingency contingency contingency contingency contingency contingency communication, communication, communication, communication, communication, communication, communication, communication, communication, communication, communication, and the 

codifi cation of formal communication and reporting policies codification of formal communication communication communication communication communication communication communication communication communication communication communication and reporting reporting reporting reporting reporting reporting reporting reporting reporting reporting reporting policies policies policies policies policies policies policies policies policies policies policies 

and procedures. This cultural change requires that NASA re- and procedures. procedures. procedures. procedures. procedures. procedures. procedures. procedures. procedures. procedures. This cultural cultural cultural cultural cultural cultural cultural cultural cultural cultural change requires requires requires requires requires requires requires requires requires requires that NASA return to the process that considers anomalies as problems until turn to the process process process process process process process process process process process that considers considers considers considers considers considers considers considers considers considers considers anomalies anomalies anomalies anomalies anomalies anomalies anomalies anomalies anomalies anomalies anomalies as problems problems problems problems problems problems problems problems problems problems problems until 

proven otherwise. This philosophy, supported by a clear chain of proven otherwise. otherwise. otherwise. otherwise. otherwise. otherwise. otherwise. otherwise. otherwise. otherwise. This philosophy philosophy philosophy philosophy philosophy philosophy philosophy philosophy philosophy philosophy, supported supported supported supported supported supported supported supported supported supported by a clear chain of 

command also supports contingency communication, or escala- command command command command command command command command command command command also supports supports supports supports supports supports supports supports supports supports supports contingency contingency contingency contingency contingency contingency contingency contingency contingency contingency contingency communication, communication, communication, communication, communication, communication, communication, communication, communication, communication, communication, or escala- escala- escala- escala- escala- escala- escala- escala- escala- escala- escalation paths, so that disagreements can be addressed to enhance tion paths, so that disagreements disagreements disagreements disagreements disagreements disagreements disagreements disagreements disagreements disagreements can be addressed addressed addressed addressed addressed addressed addressed addressed addressed addressed to enhance enhance enhance enhance enhance enhance enhance enhance enhance enhance 

anomaly resolution. Furthermore, this process needs to be well anomaly anomaly anomaly anomaly anomaly anomaly anomaly anomaly anomaly anomaly anomaly resolution. resolution. resolution. resolution. resolution. resolution. resolution. resolution. resolution. resolution. resolution. Furthermore, Furthermore, Furthermore, Furthermore, Furthermore, Furthermore, Furthermore, Furthermore, Furthermore, Furthermore, Furthermore, this process process process process process process process process process process process needs to be well 

documented and rehearsed so that procedures in normal and ex- documented documented documented documented documented documented documented documented documented documented and rehearsed rehearsed rehearsed rehearsed rehearsed rehearsed rehearsed rehearsed rehearsed rehearsed so that procedures procedures procedures procedures procedures procedures procedures procedures procedures procedures in normal and extreme situations are well understood.

From a cultural standpoint, one of the major resonating com- From a cultural cultural cultural cultural cultural cultural cultural cultural cultural cultural standpoint, standpoint, standpoint, standpoint, standpoint, standpoint, standpoint, standpoint, standpoint, standpoint, one of the major resonating resonating resonating resonating resonating resonating resonating resonating resonating resonating communication themes is “shooting the messenger” in that bringing munication munication munication munication munication munication munication munication munication munication munication themes is “shooting “shooting “shooting “shooting “shooting “shooting “shooting “shooting “shooting “shooting “shooting the messenger” messenger” messenger” messenger” messenger” messenger” messenger” messenger” messenger” messenger” messenger” in that bringing bringing bringing bringing bringing bringing bringing bringing bringing bringing bringing 

up issues can be career limiting. It may be perceived that it is up issues can be career limiting. limiting. limiting. limiting. limiting. limiting. limiting. limiting. limiting. limiting. It may be perceived perceived perceived perceived perceived perceived perceived perceived perceived perceived that it is 

counterproductive to brand what some people have to say as counterproductive counterproductive counterproductive counterproductive counterproductive counterproductive counterproductive counterproductive counterproductive counterproductive counterproductive to brand what some people have to say as 

“minority views.” The prevailing culture should recognize the “minority “minority “minority “minority “minority “minority “minority “minority “minority “minority views.” views.” views.” views.” views.” views.” views.” views.” views.” views.” The prevailing prevailing prevailing prevailing prevailing prevailing prevailing prevailing prevailing prevailing culture culture culture culture culture culture culture culture culture culture should recognize recognize recognize recognize recognize recognize recognize recognize recognize recognize the 

value to be derived from all viewpoints. Confi dence in prevailing value to be derived derived derived derived derived derived derived derived derived derived from all viewpoints. viewpoints. viewpoints. viewpoints. viewpoints. viewpoints. viewpoints. viewpoints. viewpoints. viewpoints. Confidence in prevailing prevailing prevailing prevailing prevailing prevailing prevailing prevailing prevailing prevailing 

views may actually be strengthened by being tested by alterna- views may actually actually actually actually actually actually actually actually actually actually be strengthened strengthened strengthened strengthened strengthened strengthened strengthened strengthened strengthened strengthened by being tested by alterna- alterna- alterna- alterna- alterna- alterna- alterna- alterna- alterna- alternative views.

The feedback from Safety and Mission Success Week reinforced The feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback from Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Success Success Success Success Success Success Success Success Success Success Week reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced 

the Diaz Team assessment: the Diaz Team assessment:

» When concerns are raised, the prevailing attitude in 

NASA management is to require that the concerned NASA management is to require that the concerned 

person or organization prove that something is a person or organization prove that something is a 

problem before action will be taken. The action may be problem before action will be taken. The action may be 

just more analysis and testing. If the concerned person 

or organization cannot furnish data to prove a problem or organization cannot furnish data to prove a problem 

exists, no action will be taken.

» One of the barriers that should be broken down is the 

communication barrier. The NASA workforce should communication barrier. The NASA workforce should 

feel comfortable to bring forward comments. 

» Why is it not OK to ask Why? Why is it not OK to ask Why?

» There is fear of reprisal for openly communicating dissenting opinions.

» Most are reluctant to say anything for fear of criticism 

or they feel it isnʼt worth it. People have tried in the or they feel it isnʼt worth it. People have tried in the 

past to point things out but know itʼs not going to get past to point things out but know itʼs not going to get 

them anywhere. NASA culture does not encourage or them anywhere. NASA culture does not encourage or 

reward people who speak out.

» There is a lack of a formal and effective structure to There is a lack of a formal and effective structure to 

facilitate information fl ow up and down the manage- facilitate information flow up and down the management chain.

The Safety and Mission Success feedback indicated a sense from The Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Success Success Success Success Success Success Success Success Success Success feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback indicated indicated indicated indicated indicated indicated indicated indicated indicated indicated a sense from 

some in the workforce that they have lost the ability to participate some in the workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce that they have lost the ability ability ability ability ability ability ability ability ability ability ability to participate participate participate participate participate participate participate participate participate participate participate 

in the decision-making process. In part, this may be due to the in the decision-making decision-making decision-making decision-making decision-making decision-making decision-making decision-making decision-making decision-making process. process. process. process. process. process. process. process. process. process. In part, this may be due to the 

fear of retribution for airing minority views, but it is amplifi ed by fear of retribution retribution retribution retribution retribution retribution retribution retribution retribution retribution retribution for airing minority minority minority minority minority minority minority minority minority minority minority views, but it is amplifi amplied by 

the concern that too many fi lters and “too much secrecy across the concern concern concern concern concern concern concern concern concern concern that too many filters and “too much secrecy secrecy secrecy secrecy secrecy secrecy secrecy secrecy secrecy secrecy across 

the whole management chain” limit the communication fl ow. the whole management management management management management management management management management management chain” limit the communication communication communication communication communication communication communication communication communication communication flow. 

Another concern is that personnel do not understand their orga- Another Another Another Another Another Another Another Another Another Another Another concern concern concern concern concern concern concern concern concern concern concern is that personnel personnel personnel personnel personnel personnel personnel personnel personnel personnel personnel do not understand understand understand understand understand understand understand understand understand understand understand their organizations or the management rationale for their establishment as nizations nizations nizations nizations nizations nizations nizations nizations nizations nizations or the management management management management management management management management management management rationale rationale rationale rationale rationale rationale rationale rationale rationale rationale for their establishment establishment establishment establishment establishment establishment establishment establishment establishment establishment as 

CAIB Report Chapter 6, p170:

Management decisions made during Columbia’s fi nal fl ight refl ect missed opportunities, blocked or ineffective 

communication channels, fl awed analysis, and ineffective leadership. Perhaps most striking is the fact that 

management – including Shuttle Program, Mission Management Team, Mission Evaluation Room, and Flight 

Director and Mission Control – displayed no interest in understanding a problem and its implications.

5.0 COMMUNICATION
3 1
3 2

evidenced by some comments. The feedback also suggests that evidenced evidenced evidenced evidenced evidenced evidenced evidenced evidenced evidenced evidenced evidenced by some comments. comments. comments. comments. comments. comments. comments. comments. comments. comments. comments. The feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback also suggests suggests suggests suggests suggests suggests suggests suggests suggests suggests suggests that 

there is a segment of the workforce with the desire to participate there is a segment segment segment segment segment segment segment segment segment segment segment of the workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce with the desire to participate participate participate participate participate participate participate participate participate participate participate 

but who are afraid to do so. They are uncertain about their roles, but who are afraid to do so. They are uncertain uncertain uncertain uncertain uncertain uncertain uncertain uncertain uncertain uncertain uncertain uncertain about their roles, 

and have a lack of understanding of the processes for dissent. 

Employeesʼ feedback that improved communication is occur- Employeesʼ Employeesʼ Employeesʼ Employeesʼ Employeesʼ Employeesʼ Employeesʼ Employeesʼ Employeesʼ Employeesʼ Employeesʼ feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback that improved improved improved improved improved improved improved improved improved improved improved communication communication communication communication communication communication communication communication communication communication communication is occurring will be one clear sign that NASA is on the road to cul- ring will be one clear sign that NASA is on the road to cultural health. The CAIB fi ndings and Diaz Team actions identify tural health. health. health. health. health. health. health. health. health. health. health. The CAIB findings and Diaz Team actions actions actions actions actions actions actions actions actions actions actions identify identify identify identify identify identify identify identify identify identify identify 

means to start building a more effective communication strategy. means to start building building building building building building building building building building building a more effective fective fective fective fective fective fective fective fective fective fective communication communication communication communication communication communication communication communication communication communication communication strategy strategy strategy strategy strategy strategy strategy strategy strategy strategy strategy. 

However, change in communication requires that leaders adopt However However However However However However However However However However However However, change in communication communication communication communication communication communication communication communication communication communication communication communication requires requires requires requires requires requires requires requires requires requires requires requires that leaders leaders leaders leaders leaders leaders leaders leaders leaders leaders leaders leaders adopt 

different behavior and communication philosophies. different behavior behavior behavior behavior behavior behavior behavior behavior behavior and communication communication communication communication communication communication communication communication communication philosophies. philosophies. philosophies. philosophies. philosophies. philosophies. philosophies. philosophies. philosophies. Leaders 

should promote a diversity of viewpoints. Each member of the should promote promote promote promote promote promote promote promote promote promote promote promote a diversity diversity diversity diversity diversity diversity diversity diversity diversity diversity diversity diversity of viewpoints. viewpoints. viewpoints. viewpoints. viewpoints. viewpoints. viewpoints. viewpoints. viewpoints. viewpoints. viewpoints. viewpoints. Each member of the 

workforce is responsible for expressing his or her viewpoint. workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce is responsible responsible responsible responsible responsible responsible responsible responsible responsible responsible for expressing expressing expressing expressing expressing expressing expressing expressing expressing expressing his or her viewpoint. viewpoint. viewpoint. viewpoint. viewpoint. viewpoint. viewpoint. viewpoint. viewpoint. viewpoint. The 

structure of the organization and chains of command should be structure structure structure structure structure structure structure structure structure structure structure structure of the organization ganization ganization ganization ganization ganization ganization ganization ganization ganization ganization ganization and chains of command command command command command command command command command command command command should be 

suffi ciently fl exible to support, encourage, and objectively evalu- sufficiently ciently ciently ciently ciently ciently ciently ciently ciently ciently ciently flexible to support, support, support, support, support, support, support, support, support, support, support, encourage, encourage, encourage, encourage, encourage, encourage, encourage, encourage, encourage, encourage, encourage, and objectively objectively objectively objectively objectively objectively objectively objectively objectively objectively objectively evaluate all viewpoints, ensuring decision-making is based on facts. ate all viewpoints, viewpoints, viewpoints, viewpoints, viewpoints, viewpoints, viewpoints, viewpoints, viewpoints, viewpoints, viewpoints, viewpoints, ensuring ensuring ensuring ensuring ensuring ensuring ensuring ensuring ensuring ensuring ensuring ensuring decision-making decision-making decision-making decision-making decision-making decision-making decision-making decision-making decision-making decision-making decision-making decision-making is based on facts. 

This is further discussed in the Organizational Structure section. This is further further further further further further further further further further further discussed discussed discussed discussed discussed discussed discussed discussed discussed discussed discussed in the Organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational Structure Structure Structure Structure Structure Structure Structure Structure Structure Structure Structure section. section. section. section. section. section. section. section. section. section. section. 

When vital messages are circulating freely within NASA, deci- When vital messages messages messages messages messages messages messages messages messages messages messages are circulating circulating circulating circulating circulating circulating circulating circulating circulating circulating circulating freely within NASA, decision-making will be based on the actual information at hand, not sion-making sion-making sion-making sion-making sion-making sion-making sion-making sion-making sion-making sion-making sion-making sion-making will be based on the actual information information information information information information information information information information information information at hand, not 

on the false perceptions that are all too often transmitted within a on the false perceptions perceptions perceptions perceptions perceptions perceptions perceptions perceptions perceptions perceptions perceptions that are all too often transmitted transmitted transmitted transmitted transmitted transmitted transmitted transmitted transmitted transmitted transmitted within a 

poorly communicating organization. Further, critical to effective poorly communicating communicating communicating communicating communicating communicating communicating communicating communicating communicating communicating communicating organization. ganization. ganization. ganization. ganization. ganization. ganization. ganization. ganization. ganization. ganization. ganization. Further Further Further Further Further Further Further Further Further Further Further Further, critical critical critical critical critical critical critical critical critical critical critical critical to effective fective fective fective fective fective fective fective fective fective fective fective 

communication within NASA is sharing openly with employees communication communication communication communication communication communication communication communication communication communication communication within NASA is sharing sharing sharing sharing sharing sharing sharing sharing sharing sharing sharing openly with employees employees employees employees employees employees employees employees employees employees employees 

the rationale which determined the decision. 

Fear of retribution must be eliminated. The workforce needs a Fear of retribution retribution retribution retribution retribution retribution retribution retribution retribution retribution must be eliminated. eliminated. eliminated. eliminated. eliminated. eliminated. eliminated. eliminated. eliminated. eliminated. The workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce needs a 

process to allow for dissenting opinion and intervention when process process process process process process process process process process to allow for dissenting dissenting dissenting dissenting dissenting dissenting dissenting dissenting dissenting dissenting opinion opinion opinion opinion opinion opinion opinion opinion opinion opinion and intervention intervention intervention intervention intervention intervention intervention intervention intervention intervention when 

retribution or retaliation is suspected. retribution or retaliation is suspected. The new NASA Ombuds The new NASA Ombuds 

program, recommended by the Diaz Team, should serve this pur- program, program, program, program, program, program, program, program, program, program, recommended recommended recommended recommended recommended recommended recommended recommended recommended recommended by the Diaz Team, should serve this purpose well. The Team recommended that: pose well. The Team recommended that:

• An Ombuds role be established at every Center and at 

Headquarters;

• It provide an additional and supplemental channel of 

communication for the workforce to raise signifi cant communication for the workforce to raise significant 

issues and concerns;

• It not be viewed as a substitute for any existing communication method; and

• It be a collateral duty assignment reporting directly to 

the Center Director, and at Headquarters to the Deputy the Center Director, and at Headquarters to the Deputy 

Administrator. Administrator.

The NASA Administrator announced the establishment of The NASA Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator announced announced announced announced announced announced announced announced announced announced the establishment establishment establishment establishment establishment establishment establishment establishment establishment establishment of 

NASAʼs Ombuds program in an announcement dated January NASAʼs Ombuds program program program program program program program program program program program in an announcement announcement announcement announcement announcement announcement announcement announcement announcement announcement announcement dated January January January January January January January January January January January 

24, 2004. Efforts are now underway at each NASA Center and at 24, 2004. Efforts are now underway underway underway underway underway underway underway underway underway underway at each NASA Center and at 

NASA Headquarters to implement this program. NASA Headquarters to implement this program.

In addition to the actions in the Diaz Team Matrix that address In addition addition addition addition addition addition addition addition addition addition addition to the actions actions actions actions actions actions actions actions actions actions actions in the Diaz Team Matrix that address address address address address address address address address address address 

each R-O-F, the Diaz Team has one goal addressing the Commu- each R-O-F, the Diaz Team has one goal addressing addressing addressing addressing addressing addressing addressing addressing addressing addressing the Communication category, as shown in Table 14. nication category, as shown in Table 14.

Table 15. The Diaz Team determined that fi ve Findings could be included in the Communication Category resulting in two actions. 

Diaz # CAIB # CAIB Report Recommendations 

and Pertinent Factors Diaz Summary Discussion Diaz Action # Responsible

F41 F4.2-4 Metal objects separating from Orbiter not 

identifi ed as concern

Anomalies are problems unless proven 

otherwise 24 AE

F97 F6.3-24 Communication did not fl ow effectively up or 

down

Multi-Center programs means Agency-wide 

issue 35 AE

F99 F6.3-26 Information came through informal channels Formal reporting plans need to be codifi ed 

and rehearsed 35 AE

F100 F6.3-27 PM did not communicate well with Debris 

Assessment Team

Formal reporting plans need to be codifi ed 

and rehearsed 35 AE

F102 F6.3-29 Safety reps passive in meetings and no 

channel to voice views

Encourage workforce to raise issues across 

programs

35 AE

Table 14. The Diaz Team developed one goal for Communication.

Communication – Diaz Team Goal

The Agency should continue the dialog that it began with the NASA workforce during Safety and Mission Success Week.
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6.0 PROCESSES AND RULES

NASA has not followed its own rules.

Agency-wide Themes

• Requirements, policies, procedures, and directives must be examined and adhered to.

• Best practices and lessons learned must be 

incorporated.

• The entire workforce must be aware of and 

understand the rules.

6.1 INTRODUCTION NTRODUCTION

The Diaz Team Report category of Processes and Rules addresses The Diaz Team Report category category category category category category category category category category category category of Processes Processes Processes Processes Processes Processes Processes Processes Processes Processes Processes Processes and Rules addresses addresses addresses addresses addresses addresses addresses addresses addresses addresses addresses addresses 

how NASA conducts its programs and operational missions. The how NASA conducts conducts conducts conducts conducts conducts conducts conducts conducts conducts conducts its programs programs programs programs programs programs programs programs programs programs programs and operational operational operational operational operational operational operational operational operational operational operational missions. missions. missions. missions. missions. missions. missions. missions. missions. missions. missions. The 

nature of this category is multi-faceted. In a complex government nature of this category category category category category category category category category category category is multi-faceted. multi-faceted. multi-faceted. multi-faceted. multi-faceted. multi-faceted. multi-faceted. multi-faceted. multi-faceted. multi-faceted. multi-faceted. In a complex complex complex complex complex complex complex complex complex complex complex government government government government government government government government government government government 

organization such as NASA, many policies, requirements, and organization ganization ganization ganization ganization ganization ganization ganization ganization ganization ganization such as NASA, many policies, policies, policies, policies, policies, policies, policies, policies, policies, policies, policies, requirements, requirements, requirements, requirements, requirements, requirements, requirements, requirements, requirements, requirements, requirements, and 

procedures are developed for employees to follow in the conduct procedures procedures procedures procedures procedures procedures procedures procedures procedures procedures procedures are developed developed developed developed developed developed developed developed developed developed developed for employees employees employees employees employees employees employees employees employees employees employees to follow in the conduct conduct conduct conduct conduct conduct conduct conduct conduct conduct conduct 

of programs, missions, designs, tests, and operations. Included of programs, programs, programs, programs, programs, programs, programs, programs, programs, programs, programs, programs, missions, missions, missions, missions, missions, missions, missions, missions, missions, missions, missions, missions, designs, designs, designs, designs, designs, designs, designs, designs, designs, designs, designs, designs, tests, and operations. operations. operations. operations. operations. operations. operations. operations. operations. operations. operations. operations. Included Included Included Included Included Included Included Included Included Included Included Included 

in this category are the many processes for managing the exter- in this category category category category category category category category category category category are the many processes processes processes processes processes processes processes processes processes processes processes for managing managing managing managing managing managing managing managing managing managing managing the external workforce of NASA through its large cadre of contractors. nal workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce of NASA through through through through through through through through through through through through its large cadre of contractors. contractors. contractors. contractors. contractors. contractors. contractors. contractors. contractors. contractors. contractors. contractors. 

Many of these rules and processes were established as a result Many of these rules and processes processes processes processes processes processes processes processes processes processes processes were established established established established established established established established established established established as a result 

of adoption of best practices or lessons learned from program of adoption adoption adoption adoption adoption adoption adoption adoption adoption adoption adoption adoption of best practices practices practices practices practices practices practices practices practices practices practices practices or lessons lessons lessons lessons lessons lessons lessons lessons lessons lessons lessons lessons learned learned learned learned learned learned learned learned learned learned learned learned from program program program program program program program program program program program program 

history. Some are the result of informal adoption into the culture history history history history history history history history history history history. Some are the result of informal informal informal informal informal informal informal informal informal informal informal adoption adoption adoption adoption adoption adoption adoption adoption adoption adoption adoption into the culture culture culture culture culture culture culture culture culture culture culture 

of NASA – in essence – how NASA conducts its business. Oth- of NASA – in essence essence essence essence essence essence essence essence essence essence essence – how NASA conducts conducts conducts conducts conducts conducts conducts conducts conducts conducts conducts its business. business. business. business. business. business. business. business. business. business. business. Others may be confl icting among organizations, outdated, or merely ers may be conflicting among organizations, ganizations, ganizations, ganizations, ganizations, ganizations, ganizations, ganizations, ganizations, ganizations, ganizations, ganizations, outdated, outdated, outdated, outdated, outdated, outdated, outdated, outdated, outdated, outdated, outdated, outdated, or merely 

bureaucratic in nature offering little concrete benefi t. The CAIB bureaucratic bureaucratic bureaucratic bureaucratic bureaucratic bureaucratic bureaucratic bureaucratic bureaucratic bureaucratic bureaucratic in nature offering little concrete concrete concrete concrete concrete concrete concrete concrete concrete concrete concrete benefit. The CAIB 

examined NASAʼs processes and rules closely as it related to the examined examined examined examined examined examined examined examined examined examined examined examined NASAʼs processes processes processes processes processes processes processes processes processes processes processes processes and rules closely closely closely closely closely closely closely closely closely closely closely closely as it related related related related related related related related related related related related to the 

Shuttle accident and arrived at some key conclusions. 

6.2 CATEGORY ATEGORY R-O-F S R-O-F SUMMARY

Most of the 40 Diaz Team actions defi ned for Agency-wide ap- Most of the 40 Diaz Team actions actions actions actions actions actions actions actions actions actions actions defined for Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide applicability require that the policies governing the R-O-F area be plicability plicability plicability plicability plicability plicability plicability plicability plicability plicability plicability require require require require require require require require require require require that the policies policies policies policies policies policies policies policies policies policies policies governing governing governing governing governing governing governing governing governing governing governing the R-O-F area be 

reviewed and modifi ed if necessary. But in this category specifi - reviewed reviewed reviewed reviewed reviewed reviewed reviewed reviewed reviewed reviewed reviewed reviewed and modified if necessary necessary necessary necessary necessary necessary necessary necessary necessary necessary necessary necessary. But in this category category category category category category category category category category category category specifi specically, there were two recommendations, three observations, and cally, there were two recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, three observations, observations, observations, observations, observations, observations, observations, observations, observations, observations, observations, and 

six fi ndings that the Diaz Team determined had broad NASA ap- six findings that the Diaz Team determined determined determined determined determined determined determined determined determined determined determined determined had broad NASA applicability to Processes and Rules. Table 17 shows these 11 R-O- plicability plicability plicability plicability plicability plicability plicability plicability plicability plicability plicability to Processes Processes Processes Processes Processes Processes Processes Processes Processes Processes Processes and Rules. Table 17 shows these 11 R-OFs in brief summary statement form, along with brief discussion Fs in brief summary summary summary summary summary summary summary summary summary summary summary summary statement statement statement statement statement statement statement statement statement statement statement statement form, along with brief discussion discussion discussion discussion discussion discussion discussion discussion discussion discussion discussion discussion 

points on NASA applicability. Three themes emerge from these points on NASA applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability. Three themes emerge from these 

discussion points as highlighted in the bullet points above.

6.3 DISCUSSION ISCUSSION

The CAIB recommendations described the need for the Shuttle The CAIB recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations described described described described described described described described described described described the need for the Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle 

Program to integrate the ability to cover launches with an up- Program Program Program Program Program Program Program Program Program Program Program Program to integrate integrate integrate integrate integrate integrate integrate integrate integrate integrate integrate integrate the ability ability ability ability ability ability ability ability ability ability ability ability to cover launches launches launches launches launches launches launches launches launches launches launches launches with an upgraded imaging system and include its status in the Launch Com- graded imaging imaging imaging imaging imaging imaging imaging imaging imaging imaging imaging system and include include include include include include include include include include include its status in the Launch Commit Criteria and in monitoring key events. When applied broadly, mit Criteria Criteria Criteria Criteria Criteria Criteria Criteria Criteria Criteria Criteria Criteria Criteria and in monitoring monitoring monitoring monitoring monitoring monitoring monitoring monitoring monitoring monitoring monitoring monitoring key events. events. events. events. events. events. events. events. events. events. events. events. When applied applied applied applied applied applied applied applied applied applied applied applied broadly broadly broadly broadly broadly broadly broadly broadly broadly broadly broadly broadly, 

NASA must look at all programs and determine the appropriate NASA must look at all programs programs programs programs programs programs programs programs programs programs programs and determine determine determine determine determine determine determine determine determine determine determine the appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate 

monitoring of critical events and the pre-commit data criteria for monitoring monitoring monitoring monitoring monitoring monitoring monitoring monitoring monitoring monitoring monitoring of critical critical critical critical critical critical critical critical critical critical critical events and the pre-commit pre-commit pre-commit pre-commit pre-commit pre-commit pre-commit pre-commit pre-commit pre-commit pre-commit data criteria criteria criteria criteria criteria criteria criteria criteria criteria criteria criteria for 

initiating those events. But the availability of data is not enough. initiating initiating initiating initiating initiating initiating initiating initiating initiating initiating initiating initiating those events. events. events. events. events. events. events. events. events. events. events. events. But the availability availability availability availability availability availability availability availability availability availability availability availability of data is not enough. enough. enough. enough. enough. enough. enough. enough. enough. enough. enough. enough. 

Appropriate integration of the data to make informed decisions Appropriate Appropriate Appropriate Appropriate Appropriate Appropriate Appropriate Appropriate Appropriate Appropriate Appropriate integration integration integration integration integration integration integration integration integration integration integration of the data to make informed informed informed informed informed informed informed informed informed informed informed decisions decisions decisions decisions decisions decisions decisions decisions decisions decisions decisions 

must be tied to processes and rules that ensure its timely avail- must be tied to processes processes processes processes processes processes processes processes processes processes processes and rules that ensure its timely availability. Programs that create the mechanisms for generating ability ability ability ability ability ability ability ability ability ability. Programs Programs Programs Programs Programs Programs Programs Programs Programs Programs that create the mechanisms mechanisms mechanisms mechanisms mechanisms mechanisms mechanisms mechanisms mechanisms mechanisms for generating generating generating generating generating generating generating generating generating generating 

decision-making data, yet continue to operate in the face of decision-making decision-making decision-making decision-making decision-making decision-making decision-making decision-making decision-making decision-making decision-making data, yet continue continue continue continue continue continue continue continue continue continue continue to operate operate operate operate operate operate operate operate operate operate operate in the face of 

inadequate, untimely, or failed data fl ow, increase the level of inadequate, inadequate, inadequate, inadequate, inadequate, inadequate, inadequate, inadequate, inadequate, inadequate, untimely untimely untimely untimely untimely untimely untimely untimely untimely untimely, or failed data flow, increase increase increase increase increase increase increase increase increase increase the level of 

program risk and decrease safety. The Board, in essence, stated program program program program program program program program program program program risk and decrease decrease decrease decrease decrease decrease decrease decrease decrease decrease decrease safety. The Board, in essence, essence, essence, essence, essence, essence, essence, essence, essence, essence, essence, stated 

that NASA must set required processes that ensure accurate and that NASA must set required required required required required required required required required required processes processes processes processes processes processes processes processes processes processes that ensure accurate accurate accurate accurate accurate accurate accurate accurate accurate accurate and 

timely information fl ow and then “follow the rules” established timely information information information information information information information information information information information flow and then “follow “follow “follow “follow “follow “follow “follow “follow “follow “follow “follow the rules” established established established established established established established established established established established 

for making decisions with this data. 

Throughout the CAIB Report, a recurring observation was that Throughout Throughout Throughout Throughout Throughout Throughout Throughout Throughout Throughout Throughout Throughout the CAIB Report, Report, Report, Report, Report, Report, Report, Report, Report, Report, Report, a recurring recurring recurring recurring recurring recurring recurring recurring recurring recurring recurring observation observation observation observation observation observation observation observation observation observation observation was that 

NASA did not follow its own rules. One of the fi ndings directly NASA did not follow its own rules. One of the findings directly directly directly directly directly directly directly directly directly directly 

stated that NASA did not follow its own rules on evaluating stated that NASA did not follow its own rules on evaluating evaluating evaluating evaluating evaluating evaluating evaluating evaluating evaluating evaluating evaluating 

foam-shedding from the External Tank. The Board discovered foam-shedding foam-shedding foam-shedding foam-shedding foam-shedding foam-shedding foam-shedding foam-shedding foam-shedding foam-shedding from the External External External External External External External External External External Tank. The Board discovered discovered discovered discovered discovered discovered discovered discovered discovered discovered 

organizational practices detrimental to safety and reliability in- organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational practices practices practices practices practices practices practices practices practices practices practices detrimental detrimental detrimental detrimental detrimental detrimental detrimental detrimental detrimental detrimental detrimental to safety and reliability reliability reliability reliability reliability reliability reliability reliability reliability reliability reliability including the “evolution of an informal chain of command and de- cluding cluding cluding cluding cluding cluding cluding cluding cluding cluding the “evolution “evolution “evolution “evolution “evolution “evolution “evolution “evolution “evolution “evolution of an informal informal informal informal informal informal informal informal informal informal chain of command command command command command command command command command command and decision-making processes that operated outside the organizationʼs cision-making cision-making cision-making cision-making cision-making cision-making cision-making cision-making cision-making cision-making processes processes processes processes processes processes processes processes processes processes that operated operated operated operated operated operated operated operated operated operated outside outside outside outside outside outside outside outside outside outside the organizationʼ ganizationʼ ganizationʼ ganizationʼ ganizationʼ ganizationʼ ganizationʼ ganizationʼ ganizationʼ ganizationʼs 

rules.” Yet, the Board believed rules which were followed within rules.” rules.” rules.” rules.” rules.” rules.” rules.” rules.” rules.” rules.” Yet, the Board believed believed believed believed believed believed believed believed believed believed rules which were followed followed followed followed followed followed followed followed followed followed within 

NASA were often more bureaucratic and had the effect of stifl ing NASA were often more bureaucratic bureaucratic bureaucratic bureaucratic bureaucratic bureaucratic bureaucratic bureaucratic bureaucratic bureaucratic and had the effect of stifling 

critical communication. According to the CAIB, “program lead- critical critical critical critical critical critical critical critical critical critical critical communication. communication. communication. communication. communication. communication. communication. communication. communication. communication. communication. According According According According According According According According According According According to the CAIB, “program “program “program “program “program “program “program “program “program “program “program leaders spent at least as much time making sure hierarchical rules and ers spent at least as much time making sure hierarchical hierarchical hierarchical hierarchical hierarchical hierarchical hierarchical hierarchical hierarchical hierarchical rules and 

processes were followed as they did trying to establish why any- processes processes processes processes processes processes processes processes processes processes processes were followed followed followed followed followed followed followed followed followed followed followed as they did trying to establish establish establish establish establish establish establish establish establish establish establish why anyone would want a picture of the Orbiter.” However, the managers one would want a picture picture picture picture picture picture picture picture picture picture of the Orbiter Orbiter Orbiter Orbiter Orbiter Orbiter Orbiter Orbiter Orbiter Orbiter.” However However However However However However However However However However, the managers managers managers managers managers managers managers managers managers managers 

themselves would operate by their own rules while requiring themselves themselves themselves themselves themselves themselves themselves themselves themselves themselves themselves would operate operate operate operate operate operate operate operate operate operate operate by their own rules while requiring requiring requiring requiring requiring requiring requiring requiring requiring requiring requiring 

engineers to adhere to a “stifl ing protocol.” engineers to adhere to a “stifling protocol.” 

The feedback from Safety and Mission Success Week reinforced The feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback from Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Success Success Success Success Success Success Success Success Success Success Success Week reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced 

the Diaz Team assessment: the Diaz Team assessment:

» We say all the right language and have all the right We say all the right language and have all the right 

procedures, but donʼt follow them. procedures, but donʼt follow them.

» When internal and contracted requirements are not 

fi rmly established, employees can feel that nothing is firmly established, employees can feel that nothing is 

mandatory. mandatory. 

» Crew Resource Management is a process used in other 

industries that can be applied across NASA and in industries that can be applied across NASA and in 

particular mission-critical management positions. 

The observations and fi ndings of the CAIB also revealed a need The observations observations observations observations observations observations observations observations observations observations and findings of the CAIB also revealed revealed revealed revealed revealed revealed revealed revealed revealed revealed a need 

for NASA to examine its processes, make changes where appro- for NASA to examine examine examine examine examine examine examine examine examine examine examine its processes, processes, processes, processes, processes, processes, processes, processes, processes, processes, processes, make changes changes changes changes changes changes changes changes changes changes changes where appropriate, and apply the processes uniformly across programs. CAIB priate, priate, priate, priate, priate, priate, priate, priate, priate, priate, and apply the processes processes processes processes processes processes processes processes processes processes uniformly uniformly uniformly uniformly uniformly uniformly uniformly uniformly uniformly uniformly across programs. programs. programs. programs. programs. programs. programs. programs. programs. programs. CAIB 

fi ndings included the need for improved and uniform statistical findings included included included included included included included included included included the need for improved improved improved improved improved improved improved improved improved improved and uniform uniform uniform uniform uniform uniform uniform uniform uniform uniform statistical statistical statistical statistical statistical statistical statistical statistical statistical statistical 

sampling, audit, and certifi cation processes. The CAIB observed sampling, sampling, sampling, sampling, sampling, sampling, sampling, sampling, sampling, sampling, audit, and certifi certication processes. processes. processes. processes. processes. processes. processes. processes. processes. processes. The CAIB observed observed observed observed observed observed observed observed observed observed 

that NASA needs an oversight process for work performed and that NASA needs an oversight oversight oversight oversight oversight oversight oversight oversight oversight oversight process process process process process process process process process process for work performed performed performed performed performed performed performed performed performed performed and 

documented by United Space Alliance to ensure process control, documented documented documented documented documented documented documented documented documented documented documented by United Space Alliance Alliance Alliance Alliance Alliance Alliance Alliance Alliance Alliance Alliance Alliance to ensure process process process process process process process process process process process control, control, control, control, control, control, control, control, control, control, control, 

compliance, and consistency. Application of these processes is compliance, compliance, compliance, compliance, compliance, compliance, compliance, compliance, compliance, compliance, and consistency consistency consistency consistency consistency consistency consistency consistency consistency consistency. Application Application Application Application Application Application Application Application Application Application of these processes processes processes processes processes processes processes processes processes processes is 

important for all NASA programs. important for all NASA programs.

Many Safety and Mission Success Week comments and recent Many Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Success Success Success Success Success Success Success Success Success Success Success Week comments comments comments comments comments comments comments comments comments comments comments and recent 

events validated ideas and themes related to Agency-wide pro- events validated validated validated validated validated validated validated validated validated validated ideas and themes related related related related related related related related related related to Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide processes and their uniform application across NASA. The feedback cesses and their uniform uniform uniform uniform uniform uniform uniform uniform uniform uniform application application application application application application application application application application across NASA. The feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback 

suggested technology development processes are needed to im- suggested suggested suggested suggested suggested suggested suggested suggested suggested suggested suggested technology technology technology technology technology technology technology technology technology technology technology development development development development development development development development development development development processes processes processes processes processes processes processes processes processes processes processes are needed to improve legacy system operation and safety, and mission success. prove legacy system operation and safety, and mission success. 

CAIB Report Chapter 8, p203:

When it came to managers’ own actions, however, a different set of rules prevailed. The Board found that Mission Management Team decision-making operated outside the rules even as it held its engineers to a stifl ing 

protocol. Management was not able to recognize that in unprecedented conditions, when lives are on the line, 

fl exibility and democratic process should take priority over bureaucratic response.
3 5
3 6

The way in which NASA develops and executes its rules and The way in which NASA develops develops develops develops develops develops develops develops develops develops develops and executes executes executes executes executes executes executes executes executes executes executes its rules and 

processes embodies a fundamental cultural trait for the Agency. processes processes processes processes processes processes processes processes processes processes processes embodies embodies embodies embodies embodies embodies embodies embodies embodies embodies embodies a fundamental fundamental fundamental fundamental fundamental fundamental fundamental fundamental fundamental fundamental fundamental cultural cultural cultural cultural cultural cultural cultural cultural cultural cultural cultural trait for the Agency. 

Organizations that deal with high-risk technology must develop Organizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations that deal with high-risk high-risk high-risk high-risk high-risk high-risk high-risk high-risk high-risk high-risk high-risk high-risk technology technology technology technology technology technology technology technology technology technology technology technology must develop develop develop develop develop develop develop develop develop develop develop develop 

a best practices culture in order to operate safely and reliably. To a best practices practices practices practices practices practices practices practices practices practices practices culture culture culture culture culture culture culture culture culture culture culture in order to operate operate operate operate operate operate operate operate operate operate operate safely and reliably reliably reliably reliably reliably reliably reliably reliably reliably reliably reliably. To 

achieve this within NASA, all programs must develop rules that achieve achieve achieve achieve achieve achieve achieve achieve achieve achieve achieve achieve this within NASA, all programs programs programs programs programs programs programs programs programs programs programs programs must develop develop develop develop develop develop develop develop develop develop develop develop rules that 

lead to increased communication and enhanced decision-making. lead to increased increased increased increased increased increased increased increased increased increased increased communication communication communication communication communication communication communication communication communication communication communication and enhanced enhanced enhanced enhanced enhanced enhanced enhanced enhanced enhanced enhanced enhanced decision-making. decision-making. decision-making. decision-making. decision-making. decision-making. decision-making. decision-making. decision-making. decision-making. decision-making. 

When created properly, rules adhere to the chain-of-command, When created created created created created created created created created created created created properly properly properly properly properly properly properly properly properly properly properly properly, rules adhere to the chain-of-command, chain-of-command, chain-of-command, chain-of-command, chain-of-command, chain-of-command, chain-of-command, chain-of-command, chain-of-command, chain-of-command, chain-of-command, chain-of-command, 

are understood, uniformly apply, allow expression of minority are understood, understood, understood, understood, understood, understood, understood, understood, understood, understood, understood, uniformly uniformly uniformly uniformly uniformly uniformly uniformly uniformly uniformly uniformly uniformly apply, allow expression expression expression expression expression expression expression expression expression expression expression of minority minority minority minority minority minority minority minority minority minority minority 

opinions, and have the fl exibility to reveal critical safety and opinions, opinions, opinions, opinions, opinions, opinions, opinions, opinions, opinions, opinions, opinions, and have the flexibility exibility exibility exibility exibility exibility exibility exibility exibility exibility exibility to reveal critical critical critical critical critical critical critical critical critical critical critical safety and 

life-threatening issues in a timely manner. They certainly must life-threatening life-threatening life-threatening life-threatening life-threatening life-threatening life-threatening life-threatening life-threatening life-threatening life-threatening life-threatening issues in a timely manner. They certainly certainly certainly certainly certainly certainly certainly certainly certainly certainly certainly certainly must 

not stifl e communication, evoke fear of retribution, or be applied not stifle communication, communication, communication, communication, communication, communication, communication, communication, communication, communication, communication, evoke fear of retribution, retribution, retribution, retribution, retribution, retribution, retribution, retribution, retribution, retribution, retribution, or be applied applied applied applied applied applied applied applied applied applied applied 

inconsistently from one group to another. inconsistently from one group to another. 

Best practices in processes imply setting uniform standards and Best practices practices practices practices practices practices practices practices practices practices practices practices in processes processes processes processes processes processes processes processes processes processes processes processes imply setting setting setting setting setting setting setting setting setting setting setting setting uniform uniform uniform uniform uniform uniform uniform uniform uniform uniform uniform uniform standards standards standards standards standards standards standards standards standards standards standards standards and 

requirements for both NASA and its contractor community. The requirements requirements requirements requirements requirements requirements requirements requirements requirements requirements requirements for both NASA and its contractor contractor contractor contractor contractor contractor contractor contractor contractor contractor contractor community community community community community community community community community community community. The 

most modern technology, techniques, and methodologies are in- most modern technology technology technology technology technology technology technology technology technology technology technology technology, techniques, techniques, techniques, techniques, techniques, techniques, techniques, techniques, techniques, techniques, techniques, techniques, and methodologies methodologies methodologies methodologies methodologies methodologies methodologies methodologies methodologies methodologies methodologies methodologies are incorporated in a best practice environment to provide timely and corporated corporated corporated corporated corporated corporated corporated corporated corporated corporated in a best practice practice practice practice practice practice practice practice practice practice environment environment environment environment environment environment environment environment environment environment to provide provide provide provide provide provide provide provide provide provide timely and 

comprehensive information to decision makers. For NASA, this comprehensive comprehensive comprehensive comprehensive comprehensive comprehensive comprehensive comprehensive comprehensive comprehensive information information information information information information information information information information to decision decision decision decision decision decision decision decision decision decision makers. makers. makers. makers. makers. makers. makers. makers. makers. makers. For NASA, this 

means Agency-wide analysis of its current processes on a con- means Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide analysis analysis analysis analysis analysis analysis analysis analysis analysis analysis analysis of its current current current current current current current current current current current processes processes processes processes processes processes processes processes processes processes processes on a continuing basis to make sure they are relevant, technically sound, tinuing tinuing tinuing tinuing tinuing tinuing tinuing tinuing tinuing tinuing basis to make sure they are relevant, relevant, relevant, relevant, relevant, relevant, relevant, relevant, relevant, relevant, technically technically technically technically technically technically technically technically technically technically sound, 

and applied in a consistent manner. Many industrial and gov- and applied applied applied applied applied applied applied applied applied applied applied in a consistent consistent consistent consistent consistent consistent consistent consistent consistent consistent consistent manner. Many industrial industrial industrial industrial industrial industrial industrial industrial industrial industrial industrial and government organizations are identifying best practices by bench- ernment ernment ernment ernment ernment ernment ernment ernment ernment ernment organizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations are identifying identifying identifying identifying identifying identifying identifying identifying identifying identifying best practices practices practices practices practices practices practices practices practices practices by benchmarking other leading organizations and adopting a culture of marking marking marking marking marking marking marking marking marking marking marking other leading leading leading leading leading leading leading leading leading leading leading organizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations and adopting adopting adopting adopting adopting adopting adopting adopting adopting adopting adopting a culture culture culture culture culture culture culture culture culture culture culture of 

continuous improvement. NASA can look to these organizations continuous continuous continuous continuous continuous continuous continuous continuous continuous continuous improvement. improvement. improvement. improvement. improvement. improvement. improvement. improvement. improvement. improvement. NASA can look to these organizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations 

to provide valuable lessons on how to transform the Agencyʼs to provide provide provide provide provide provide provide provide provide provide valuable valuable valuable valuable valuable valuable valuable valuable valuable valuable lessons lessons lessons lessons lessons lessons lessons lessons lessons lessons on how to transform transform transform transform transform transform transform transform transform transform the Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼs 

culture into one that values workforce input and seeks the right culture culture culture culture culture culture culture culture culture culture culture into one that values workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce input and seeks the right 

way of doing business for the right reasons.

In addition to the actions in the Diaz Team Matrix that address In addition addition addition addition addition addition addition addition addition addition to the actions actions actions actions actions actions actions actions actions actions in the Diaz Team Matrix that address address address address address address address address address address 

each R-O-F, the Diaz Team has one goal addressing the Process each R-O-F, the Diaz Team has one goal addressing addressing addressing addressing addressing addressing addressing addressing addressing addressing addressing the Process Process Process Process Process Process Process Process Process Process Process 

and Rules category, as shown in Table 16. and Rules category, as shown in Table 16.

Table 17. The Diaz Team determined that two Recommendations, three Observations, and six Findings could be included in the 

Processes & Rules Category resulting in seven actions.

Diaz 

Team # CAIB # CAIB Report Recommendations and Pertinent Factors Diaz Team Discussion Action # HQ Code #

R7 R3.4-1 Upgrade imaging sytem for three views of Shuttle 

liftoff

All programs need to identify critical monitoring 

requirements 1 AE

R8 R3.4-2 Obtain and downlink hi-res images of ET separation Monitoring requirements for major events needed 2 AE

O8 O10.4-4 KSC to examine ISO 9000/9001 needs of Shuttle 

system Assess all programs for R&D or operational status 12 AE

O9 O10.5-1 Use statistical sampling for Q&E review of work 

documents

Program audits subject to rigors of statistical 

sampling needed 13 AE

O11 O10.5-3 Oversight process to statistically sample USA work 

needed

Program audits subject to rigors of statistical 

sampling needed 13 AE

F5 F3.2-5 Left bi-pod foam shedding found NASA was not 

aware of

Detailed understanding of root causes for anomalies 

needed 19 Q

F7 F3.2-7 Foam loss occurred on 80 percent of imaged 

missions

Trend analysis has to be correlated with program 

requirements 19 Q

F8 F3.2-8 Unable to determine if foam lost on 30 percent of 

missions

Programs cannot address anomalies if they are not 

observed 19 Q

F56 F6.1-1 NASA did not follow its own rules on foam-shedding Independent audits needed to identify deviations 

from specs 26 AE

F89 F6.3-16 MMT meetings occurred infrequently Operation procedures on programs need to be 

followed 28 AE

F93 F6.3-20 No one in chain held active security clearances Programs could benefi t from actively cleared people 34 X

Table 16. The Diaz Team developed one goal for Processes and Rules.

Processes and Rules – Diaz Team Goal

The Agency should conduct a review of its approach to maintaining and managing rules.
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7.0 TECHNICAL CAPABILITIES

CAIB Report Chapter 7, p179:

As a result [of the Space Flight Operations Contract], experienced engineers changed jobs, NASA grew dependent on contractors for technical support, contract monitoring requirements increased, and positions were 

subsequently staffed by less experienced engineers who were placed in management roles. Collectively, this 

eroded NASA’s in-house engineering and technical capabilities.

NASA’s in-house capabilities and expertise have 

eroded.

Agency-wide Themes

• Analytical models and simulation tools must be 

used appropriately.

• NASA must address the loss of technical expertise due to retirement and outsourcing.

• Advanced technical capabilities must be 

developed.

7.1 INTRODUCTION NTRODUCTION

NASA has always viewed itself as a cutting-edge technology NASA has always viewed itself as a cutting-edge cutting-edge cutting-edge cutting-edge cutting-edge cutting-edge cutting-edge cutting-edge cutting-edge cutting-edge cutting-edge technology technology technology technology technology technology technology technology technology technology technology 

organization with experienced scientists and engineers develop- organization ganization ganization ganization ganization ganization ganization ganization ganization ganization ganization with experienced experienced experienced experienced experienced experienced experienced experienced experienced experienced experienced scientists scientists scientists scientists scientists scientists scientists scientists scientists scientists scientists and engineers engineers engineers engineers engineers engineers engineers engineers engineers engineers engineers develop- develop- develop- develop- develop- develop- develop- develop- develop- develop- developing and applying the most modern of technology tools. During ing and applying applying applying applying applying applying applying applying applying applying applying the most modern of technology technology technology technology technology technology technology technology technology technology technology tools. During 

the investigation of the the investigation of the Columbia accident, the CAIB came to accident, the CAIB came to 

believe otherwise. There was evidence of erosion in NASAʼs believe believe believe believe believe believe believe believe believe believe believe believe otherwise. otherwise. otherwise. otherwise. otherwise. otherwise. otherwise. otherwise. otherwise. otherwise. otherwise. otherwise. There was evidence evidence evidence evidence evidence evidence evidence evidence evidence evidence evidence evidence of erosion erosion erosion erosion erosion erosion erosion erosion erosion erosion erosion erosion in NASAʼs 

technological capabilities and expertise within the Shuttle Pro- technological technological technological technological technological technological technological technological technological technological technological capabilities capabilities capabilities capabilities capabilities capabilities capabilities capabilities capabilities capabilities capabilities and expertise expertise expertise expertise expertise expertise expertise expertise expertise expertise expertise within the Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Program. This included not only a defi ciency in the availability of gram. This included included included included included included included included included included included included not only a deficiency in the availability availability availability availability availability availability availability availability availability availability availability availability of 

analytical tools and simulation models, but also misapplication analytical analytical analytical analytical analytical analytical analytical analytical analytical analytical analytical tools and simulation simulation simulation simulation simulation simulation simulation simulation simulation simulation simulation models, models, models, models, models, models, models, models, models, models, models, but also misapplication misapplication misapplication misapplication misapplication misapplication misapplication misapplication misapplication misapplication misapplication 

of those tools and models that were available. Due to limited of those tools and models that were available. available. available. available. available. available. available. available. available. available. available. Due to limited limited limited limited limited limited limited limited limited limited limited 

resources and current Agency operation philosophies, NASA has resources resources resources resources resources resources resources resources resources resources resources and current current current current current current current current current current current Agency operation operation operation operation operation operation operation operation operation operation operation philosophies, philosophies, philosophies, philosophies, philosophies, philosophies, philosophies, philosophies, philosophies, philosophies, philosophies, NASA has 

come to rely on contractors to perform engineering functions on come to rely on contractors contractors contractors contractors contractors contractors contractors contractors contractors contractors contractors to perform perform perform perform perform perform perform perform perform perform perform engineering engineering engineering engineering engineering engineering engineering engineering engineering engineering engineering functions functions functions functions functions functions functions functions functions functions functions on 

its projects. In addition, downsizing without replenishment of its projects. projects. projects. projects. projects. projects. projects. projects. projects. projects. projects. projects. In addition, addition, addition, addition, addition, addition, addition, addition, addition, addition, addition, addition, downsizing downsizing downsizing downsizing downsizing downsizing downsizing downsizing downsizing downsizing downsizing downsizing without without without without without without without without without without without without replenishment replenishment replenishment replenishment replenishment replenishment replenishment replenishment replenishment replenishment replenishment replenishment of 

critical skills over the past decade has further contributed to a critical critical critical critical critical critical critical critical critical critical critical skills over the past decade has further further further further further further further further further further further contributed contributed contributed contributed contributed contributed contributed contributed contributed contributed contributed to a 

skill imbalance that is liable to be exacerbated by future retire- skill imbalance imbalance imbalance imbalance imbalance imbalance imbalance imbalance imbalance imbalance imbalance imbalance that is liable to be exacerbated exacerbated exacerbated exacerbated exacerbated exacerbated exacerbated exacerbated exacerbated exacerbated exacerbated exacerbated by future retire- retire- retire- retire- retire- retire- retire- retire- retire- retire- retire- retirements. The above conditions, occurring across the entire Agency, ments. The above conditions, conditions, conditions, conditions, conditions, conditions, conditions, conditions, conditions, conditions, conditions, occurring occurring occurring occurring occurring occurring occurring occurring occurring occurring occurring across the entire Agency, 

has resulted in a decline in NASAʼs technical capabilities and has resulted resulted resulted resulted resulted resulted resulted resulted resulted resulted resulted resulted in a decline decline decline decline decline decline decline decline decline decline decline decline in NASAʼs technical technical technical technical technical technical technical technical technical technical technical technical capabilities capabilities capabilities capabilities capabilities capabilities capabilities capabilities capabilities capabilities capabilities capabilities and 

competencies in its civil service workforce, and the over-reliance competencies competencies competencies competencies competencies competencies competencies competencies competencies competencies competencies in its civil service service service service service service service service service service service workforce, workforce, workforce, workforce, workforce, workforce, workforce, workforce, workforce, workforce, workforce, and the over-reliance -reliance -reliance -reliance -reliance -reliance -reliance -reliance -reliance -reliance -reliance 

on developmental and operational contractors.

Issues identifi ed as being associated with Technical Capabilities Issues identifi identifi identifi identifi identifi identifi identifi identifi identifi identifi identified as being associated associated associated associated associated associated associated associated associated associated associated with Technical echnical echnical echnical echnical echnical echnical echnical echnical echnical echnical Capabilities Capabilities Capabilities Capabilities Capabilities Capabilities Capabilities Capabilities Capabilities Capabilities Capabilities 

are clearly interwoven with those associated with Learning. They are clearly clearly clearly clearly clearly clearly clearly clearly clearly clearly clearly clearly interwoven interwoven interwoven interwoven interwoven interwoven interwoven interwoven interwoven interwoven interwoven interwoven with those associated associated associated associated associated associated associated associated associated associated associated associated with Learning. Learning. Learning. Learning. Learning. Learning. Learning. Learning. Learning. Learning. Learning. Learning. They 

involve the development and maintenance of skills inherent in involve involve involve involve involve involve involve involve involve involve involve the development development development development development development development development development development development and maintenance maintenance maintenance maintenance maintenance maintenance maintenance maintenance maintenance maintenance maintenance of skills inherent inherent inherent inherent inherent inherent inherent inherent inherent inherent inherent in 

the workforce and the use of technology tools.

7.2 CATEGORY ATEGORY R-O-F S R-O-F SUMMARY

Overall there were three recommendations, no observations, Overall Overall Overall Overall Overall Overall Overall Overall Overall Overall Overall there were three recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, no observations, observations, observations, observations, observations, observations, observations, observations, observations, observations, observations, 

and thirteen fi ndings that the Diaz Team determined had broad and thirteen thirteen thirteen thirteen thirteen thirteen thirteen thirteen thirteen thirteen thirteen findings that the Diaz Team determined determined determined determined determined determined determined determined determined determined determined had broad 

NASA applicability to Technical Capabilities. Table 19 shows NASA applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability to Technical echnical echnical echnical echnical echnical echnical echnical echnical echnical echnical Capabilities. Capabilities. Capabilities. Capabilities. Capabilities. Capabilities. Capabilities. Capabilities. Capabilities. Capabilities. Capabilities. Table 19 shows 

these 16 R-O-Fs in brief summary statement form, along with these 16 R-O-Fs in brief summary summary summary summary summary summary summary summary summary summary summary summary statement statement statement statement statement statement statement statement statement statement statement statement form, along with 

brief discussion points on NASA applicability. Three themes brief discussion discussion discussion discussion discussion discussion discussion discussion discussion discussion discussion points on NASA applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability. Three themes 

emerge from these discussion points as highlighted in the bullet emerge from these discussion discussion discussion discussion discussion discussion discussion discussion discussion discussion discussion discussion points as highlighted highlighted highlighted highlighted highlighted highlighted highlighted highlighted highlighted highlighted highlighted highlighted in the bullet 

points above.

7.3 DISCUSSION ISCUSSION

The fi rst CAIB recommendation describes the need for NASA to The first CAIB recommendation recommendation recommendation recommendation recommendation recommendation recommendation recommendation recommendation recommendation recommendation recommendation describes describes describes describes describes describes describes describes describes describes describes describes the need for NASA to 

develop, validate, and maintain realistic physics-based computer develop, develop, develop, develop, develop, develop, develop, develop, develop, develop, develop, validate, validate, validate, validate, validate, validate, validate, validate, validate, validate, validate, and maintain maintain maintain maintain maintain maintain maintain maintain maintain maintain maintain realistic realistic realistic realistic realistic realistic realistic realistic realistic realistic realistic physics-based physics-based physics-based physics-based physics-based physics-based physics-based physics-based physics-based physics-based physics-based computer computer computer computer computer computer computer computer computer computer computer 

models to evaluate Thermal Protection Systems in a timely man- models to evaluate evaluate evaluate evaluate evaluate evaluate evaluate evaluate evaluate evaluate evaluate Thermal Thermal Thermal Thermal Thermal Thermal Thermal Thermal Thermal Thermal Thermal Protection Protection Protection Protection Protection Protection Protection Protection Protection Protection Protection Systems Systems Systems Systems Systems Systems Systems Systems Systems Systems Systems in a timely manner. When evaluated from an Agency-wide perspective, it is clear ner. When evaluated evaluated evaluated evaluated evaluated evaluated evaluated evaluated evaluated evaluated from an Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide perspective, perspective, perspective, perspective, perspective, perspective, perspective, perspective, perspective, perspective, it is clear 

that all NASA programs need validated models and analytical that all NASA programs programs programs programs programs programs programs programs programs programs programs need validated validated validated validated validated validated validated validated validated validated validated models and analytical analytical analytical analytical analytical analytical analytical analytical analytical analytical analytical 

tools to assess the state of their systems and components. This tools to assess the state of their systems systems systems systems systems systems systems systems systems systems and components. components. components. components. components. components. components. components. components. components. This 

will enable enhanced decision-making. Moreover, this implies will enable enhanced enhanced enhanced enhanced enhanced enhanced enhanced enhanced enhanced enhanced enhanced decision-making. decision-making. decision-making. decision-making. decision-making. decision-making. decision-making. decision-making. decision-making. decision-making. decision-making. Moreover Moreover Moreover Moreover Moreover Moreover Moreover Moreover Moreover Moreover Moreover, this implies implies implies implies implies implies implies implies implies implies implies 

a need to further develop technological competency within the a need to further further further further further further further further further further develop develop develop develop develop develop develop develop develop develop technological technological technological technological technological technological technological technological technological technological competency competency competency competency competency competency competency competency competency competency within the 

Agency to effectively and consistently apply, maintain, and up- Agency to effectively fectively fectively fectively fectively fectively fectively fectively fectively fectively fectively and consistently consistently consistently consistently consistently consistently consistently consistently consistently consistently consistently apply, maintain, maintain, maintain, maintain, maintain, maintain, maintain, maintain, maintain, maintain, maintain, and update these models and tools. One way to achieve this technologi- date these models and tools. One way to achieve achieve achieve achieve achieve achieve achieve achieve achieve achieve this technologi- technologi- technologi- technologi- technologi- technologi- technologi- technologi- technologi- technological competency is to increase investment in the development and cal competency competency competency competency competency competency competency competency competency competency is to increase increase increase increase increase increase increase increase increase increase investment investment investment investment investment investment investment investment investment investment in the development development development development development development development development development development and 

training of NASAʼs scientifi c and engineering workforce in order training training training training training training training training training training training of NASAʼs scientifi scientifi scientifi scientifi scientifi scientifi scientifi scientifi scientifi scientifi scientific and engineering engineering engineering engineering engineering engineering engineering engineering engineering engineering engineering workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce in order 

to increase their skill base and overall effectiveness. to increase their skill base and overall effectiveness.

Management and decision-makers within the Agency must also Management Management Management Management Management Management Management Management Management Management and decision-makers decision-makers decision-makers decision-makers decision-makers decision-makers decision-makers decision-makers decision-makers decision-makers within the Agency must also 

maintain the ability to understand the use of, and limitations of, maintain maintain maintain maintain maintain maintain maintain maintain maintain maintain maintain the ability ability ability ability ability ability ability ability ability ability ability to understand understand understand understand understand understand understand understand understand understand understand the use of, and limitations limitations limitations limitations limitations limitations limitations limitations limitations limitations limitations of, 

the technology models and tools. Developing and training tech- the technology technology technology technology technology technology technology technology technology technology models and tools. Developing Developing Developing Developing Developing Developing Developing Developing Developing Developing and training training training training training training training training training training technically profi cient decision-makers improves safety and mission nically nically nically nically nically nically nically nically nically nically proficient decision-makers decision-makers decision-makers decision-makers decision-makers decision-makers decision-makers decision-makers decision-makers decision-makers improves improves improves improves improves improves improves improves improves improves safety and mission mission mission mission mission mission mission mission mission mission 

success. 

The feedback from Safety and Mission Success Week reinforced The feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback from Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Success Success Success Success Success Success Success Success Success Success Success Week reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced 

the Diaz Team assessment: the Diaz Team assessment:

» Technical expertise is being lost within NASA due to Technical expertise is being lost within NASA due to 

retirement and the outsourcing of technical profi ciency retirement and the outsourcing of technical proficiency 

to contractors. 

» There is a need to have more decision-makers with 

hands-on experience in addition to theoretical knowledge. 

» Technical expertise needs improvement throughout Technical expertise needs improvement throughout 

NASA.

» Technical tools and information systems are not there Technical tools and information systems are not there 

for people to effectively do their jobs. for people to effectively do their jobs. 

The other two recommendations associated with technical capa- The other two recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations associated associated associated associated associated associated associated associated associated associated with technical technical technical technical technical technical technical technical technical technical capabilities focus on the need for accurate computer-aided engineer- bilities bilities bilities bilities bilities bilities bilities bilities bilities bilities focus on the need for accurate accurate accurate accurate accurate accurate accurate accurate accurate accurate computer computer computer computer computer computer computer computer computer computer-aided engineer engineer engineer engineer engineer engineer engineer engineer engineer engineering drawings and complete as-built and closeout photographs ing drawings drawings drawings drawings drawings drawings drawings drawings drawings drawings drawings and complete complete complete complete complete complete complete complete complete complete complete as-built as-built as-built as-built as-built as-built as-built as-built as-built as-built as-built and closeout closeout closeout closeout closeout closeout closeout closeout closeout closeout closeout photographs photographs photographs photographs photographs photographs photographs photographs photographs photographs photographs 

for each mission. This core technical competency is necessary for each mission. mission. mission. mission. mission. mission. mission. mission. mission. mission. This core technical technical technical technical technical technical technical technical technical technical competency competency competency competency competency competency competency competency competency competency is necessary necessary necessary necessary necessary necessary necessary necessary necessary necessary 

Agency-wide for proper technical management of all operating Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide for proper technical technical technical technical technical technical technical technical technical technical technical management management management management management management management management management management management of all operating operating operating operating operating operating operating operating operating operating operating 

programs and missions. The theme of these two CAIB recom- programs programs programs programs programs programs programs programs programs programs and missions. missions. missions. missions. missions. missions. missions. missions. missions. missions. The theme of these two CAIB recommendations implies the Agency-wide need for technical capac- mendations mendations mendations mendations mendations mendations mendations mendations mendations mendations mendations implies implies implies implies implies implies implies implies implies implies implies the Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide need for technical technical technical technical technical technical technical technical technical technical technical capacity to maintain documentation and databases and the need to ity to maintain maintain maintain maintain maintain maintain maintain maintain maintain maintain documentation documentation documentation documentation documentation documentation documentation documentation documentation documentation and databases databases databases databases databases databases databases databases databases databases and the need to 

implement knowledge management practices and capabilities implement implement implement implement implement implement implement implement implement implement knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge management management management management management management management management management management practices practices practices practices practices practices practices practices practices practices and capabilities capabilities capabilities capabilities capabilities capabilities capabilities capabilities capabilities capabilities 

NASA-wide that are critical to technical management and deci- NASA-wide NASA-wide NASA-wide NASA-wide NASA-wide NASA-wide NASA-wide NASA-wide NASA-wide NASA-wide that are critical critical critical critical critical critical critical critical critical critical to technical technical technical technical technical technical technical technical technical technical management management management management management management management management management management and decision-making.

An example of this technical information shortfall for critical de- An example example example example example example example example example example of this technical technical technical technical technical technical technical technical technical technical information information information information information information information information information information shortfall shortfall shortfall shortfall shortfall shortfall shortfall shortfall shortfall shortfall for critical critical critical critical critical critical critical critical critical critical decisions was described in the CAIB Report. The Board observed cisions cisions cisions cisions cisions cisions cisions cisions cisions cisions cisions was described described described described described described described described described described described in the CAIB Report. Report. Report. Report. Report. Report. Report. Report. Report. Report. Report. The Board observed observed observed observed observed observed observed observed observed observed observed 

that NASA normally uses closeout photos. Yet, the Agency that NASA normally normally normally normally normally normally normally normally normally normally uses closeout closeout closeout closeout closeout closeout closeout closeout closeout closeout photos. photos. photos. photos. photos. photos. photos. photos. photos. photos. Yet, the Agency 

lacked a clear system to defi ne which critical sub-systems should lacked a clear system to define which critical critical critical critical critical critical critical critical critical critical critical sub-systems sub-systems sub-systems sub-systems sub-systems sub-systems sub-systems sub-systems sub-systems sub-systems sub-systems should 

have such photographs. Moreover, the capability for immedi- have such photographs. photographs. photographs. photographs. photographs. photographs. photographs. photographs. photographs. photographs. Moreover Moreover Moreover Moreover Moreover Moreover Moreover Moreover Moreover Moreover, the capability capability capability capability capability capability capability capability capability capability for immedi- immedi- immedi- immedi- immedi- immedi- immedi- immedi- immedi- immediate retrieval of photographs did not exist. Safety and Mission ate retrieval retrieval retrieval retrieval retrieval retrieval retrieval retrieval retrieval retrieval of photographs photographs photographs photographs photographs photographs photographs photographs photographs photographs did not exist. Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission 

Success Week responses validated the need for Agency-wide Success Success Success Success Success Success Success Success Success Success Success Week responses responses responses responses responses responses responses responses responses responses responses validated validated validated validated validated validated validated validated validated validated validated the need for Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide 

modern database tools and knowledge management systems for modern database database database database database database database database database database tools and knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge management management management management management management management management management management systems systems systems systems systems systems systems systems systems systems for 
3 9
4 0

Table 19. The Diaz Team determined that three Recommendations, and 13 Findings could be included in the Technical Capabilities 

Category resulting in six actions.

Diaz 

Team # CAIB # CAIB Report Recommendations and Pertinent Factors Diaz Team Discussion Action # Responsible

R13 R3.8-2 Develop, validate, and maintain physics-based 

models

Technical models needed for programs for 

decision-making 4 AE

R28 R10.3-1 Develop closeout photo program for critical subsystems

Photos for all programs support as-built data 

requirements 10 AE

R29 R10.3-2 Provide resources for Shuttle drawing system 

upgrade

Up-to-date confi gurations in CAD needed for all 

programs

10 AE

F2 F3.2-2 No qualifi ed non-destructive foam evaluation 

techniques

Programs need testing methods to verify 

requirements are met 18 H

F11 F3.3-2 Inadequate current RCC component testing 

techniques Need robust acceptance testing programs 18 H

F18 F3.4-3 Need for high-quality downlinked launch and 

ascent imagery

Ability to observe performance key to anomaly 

resolution 21 AE

F19 F3.4-4 Current KSC long-range camera assets 

inadequate Need appropriate resolution for anomaly detection 21 AE

F20 F3.4-5 Evaluation of STS-107 debris impact hampered by 

poor cameras

Requirements of sampling and resolution needed 

for missions 21 AE

F36 F3.8-6 Current tools inadquate for use in evaluation of 

debris damage Technical tools needed for critical decision making 4 AE

F38 F4.2-1 Bolt catcher certifi ed by extrapolation with no 

hardware testing Inappropriate hardware verifi cation to be avoided 23 AE

F39 F4.2-2 “As-fl own” bolt catchers do not have required 

safety margin

Periodic testing necessary to determine meeting 

design specs 23 AE

F51 F4.2-14 Photographs of every closeout activity not 

routinely taken

Best practices from industry include complete 

documentation 25 AE

F83 F6.3-10 Team’s tile damage assessments poorly executed Technical tools needed for critical decision making 4 AE

F84 F6.3-11 Crater initially predicted deeper tile damage Need for proper training in model use and 

limitations 4 AE

F124 F10.3-1 Engineering drawing system outdated and paperbased

Accurate engineering drawing in CAD needed for 

all programs 10 AE

F126 F10.3-3 Lack of clear and timely photo closeout system Standards for photo management system needed 

Agency-wide 10 AE

information support. Highlighted were defi ciencies in problem information information information information information information information information information information information support. support. support. support. support. support. support. support. support. support. support. Highlighted Highlighted Highlighted Highlighted Highlighted Highlighted Highlighted Highlighted Highlighted Highlighted Highlighted were deficiencies ciencies ciencies ciencies ciencies ciencies ciencies ciencies ciencies ciencies ciencies in problem problem problem problem problem problem problem problem problem problem problem 

and waiver tracking which an Agency-wide knowledge architec- and waiver tracking tracking tracking tracking tracking tracking tracking tracking tracking tracking tracking which an Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge architec- architec- architec- architec- architec- architec- architec- architec- architec- architec- architecture could address. 

Decision-making by management is often driven by cost and Decision-making Decision-making Decision-making Decision-making Decision-making Decision-making Decision-making Decision-making Decision-making Decision-making Decision-making Decision-making by management management management management management management management management management management management management is often driven by cost and 

schedule pressures. The knowledge management systems to sup- schedule schedule schedule schedule schedule schedule schedule schedule schedule schedule schedule pressures. pressures. pressures. pressures. pressures. pressures. pressures. pressures. pressures. pressures. pressures. The knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge management management management management management management management management management management management systems systems systems systems systems systems systems systems systems systems systems to support decisions are inadequate. The future ability to make techni- port decisions decisions decisions decisions decisions decisions decisions decisions decisions decisions decisions decisions are inadequate. inadequate. inadequate. inadequate. inadequate. inadequate. inadequate. inadequate. inadequate. inadequate. inadequate. inadequate. The future ability ability ability ability ability ability ability ability ability ability ability ability to make techni- techni- techni- techni- techni- techni- techni- techni- techni- techni- techni- technically credible design, test, operational, and safety decisions will cally credible credible credible credible credible credible credible credible credible credible design, design, design, design, design, design, design, design, design, design, test, operational, operational, operational, operational, operational, operational, operational, operational, operational, operational, and safety decisions decisions decisions decisions decisions decisions decisions decisions decisions decisions will 

rely on NASA systematically improving its technical capabilities rely on NASA systematically systematically systematically systematically systematically systematically systematically systematically systematically systematically improving improving improving improving improving improving improving improving improving improving its technical technical technical technical technical technical technical technical technical technical capabilities capabilities capabilities capabilities capabilities capabilities capabilities capabilities capabilities capabilities 

and competencies throughout the Agency. and competencies throughout the Agency.

In addition to the actions in the Diaz Team Matrix that address In addition addition addition addition addition addition addition addition addition addition addition to the actions actions actions actions actions actions actions actions actions actions actions in the Diaz Team Matrix that address address address address address address address address address address address 

each R-O-F, the Diaz Team has one goal addressing the Techni- each R-O-F, the Diaz Team has one goal addressing addressing addressing addressing addressing addressing addressing addressing addressing addressing the Technical Capabilities category, as shown in Table 18. cal Capabilities category, as shown in Table 18.

Table 18. The Diaz Team developed one goal for Technical Capabilities.

Technical Capabilities – Diaz Team Goal

The Agency should develop guidelines and metrics for assessing and maintaining its core competencies, including those associated 

with in-house work.
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8.0 ORGANIZATIONAL STRUCTURE

CAIB Report Executive Summary, p9:

This report discusses the attributes of an organization that could more safely and reliably operate the inherently 

risky Space Shuttle, but does not provide a detailed organizational prescription. Among those attributes are: a 

robust and independent program technical authority that has complete control over specifi cations and requirements, and waivers to them; an independent safety assurance organization with line authority over all levels of 

safety oversight; and an organizational culture that refl ects the best characteristics of a learning organization.

NASA’s safety and engineering organizations lack 

authority and independence.

Agency-wide Themes

• NASA must ensure systematic checks-and-balances are in place.

• NASA must implement independent safety and 

technical organizations.

• Roles and responsibilities must be clearly defi ned and widely understood.

8.1 INTRODUCTION NTRODUCTION

The organizational structure category embodies the NASA or- The organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational structure structure structure structure structure structure structure structure structure structure structure category category category category category category category category category category category embodies embodies embodies embodies embodies embodies embodies embodies embodies embodies embodies the NASA organizational confi guration, both formal and informal, and its ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational configuration, guration, guration, guration, guration, guration, guration, guration, guration, guration, guration, both formal and informal, informal, informal, informal, informal, informal, informal, informal, informal, informal, informal, and its 

impact on the execution of the Agencyʼs mission and programs. impact on the execution execution execution execution execution execution execution execution execution execution execution of the Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼs mission mission mission mission mission mission mission mission mission mission mission and programs. programs. programs. programs. programs. programs. programs. programs. programs. programs. programs. 

While organizational structure as a discipline can be explored While organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational structure structure structure structure structure structure structure structure structure structure structure structure as a discipline discipline discipline discipline discipline discipline discipline discipline discipline discipline discipline discipline can be explored explored explored explored explored explored explored explored explored explored explored explored 

from many perspectives, the dimensions explored in this sec- from many perspectives, perspectives, perspectives, perspectives, perspectives, perspectives, perspectives, perspectives, perspectives, perspectives, perspectives, the dimensions dimensions dimensions dimensions dimensions dimensions dimensions dimensions dimensions dimensions dimensions explored explored explored explored explored explored explored explored explored explored explored in this section deal with structural characteristics to ensure safety, sound tion deal with structural structural structural structural structural structural structural structural structural structural structural structural characteristics characteristics characteristics characteristics characteristics characteristics characteristics characteristics characteristics characteristics characteristics characteristics to ensure safety, sound 

decision making and risk management practices, effective lines decision decision decision decision decision decision decision decision decision decision decision making and risk management management management management management management management management management management management practices, practices, practices, practices, practices, practices, practices, practices, practices, practices, practices, effective fective fective fective fective fective fective fective fective fective fective lines 

of communication, clear roles of authority, accountability, re- of communication, communication, communication, communication, communication, communication, communication, communication, communication, communication, communication, communication, clear roles of authority authority authority authority authority authority authority authority authority authority authority authority, accountability accountability accountability accountability accountability accountability accountability accountability accountability accountability accountability accountability, responsibility and the implementation of an independent technical sponsibility sponsibility sponsibility sponsibility sponsibility sponsibility sponsibility sponsibility sponsibility sponsibility sponsibility and the implementation implementation implementation implementation implementation implementation implementation implementation implementation implementation implementation of an independent independent independent independent independent independent independent independent independent independent independent technical technical technical technical technical technical technical technical technical technical technical 

authority that employs systematic checks-and-balances.

8.2 CATEGORY ATEGORY R-O-F S R-O-F SUMMARY

Overall there were three recommendations, no observations, and Overall Overall Overall Overall Overall Overall Overall Overall Overall Overall Overall there were three recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, no observations, observations, observations, observations, observations, observations, observations, observations, observations, observations, observations, and 

10 fi ndings that the Diaz Team determined had broad NASA 10 findings that the Diaz Team determined determined determined determined determined determined determined determined determined determined determined determined had broad NASA

applicability to Organizational Structure. Table 21 shows these applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability to Organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational Structure. Structure. Structure. Structure. Structure. Structure. Structure. Structure. Structure. Structure. Structure. Table 21 shows these 

13 R-O-Fs in brief summary statement form, along with brief 13 R-O-Fs in brief summary summary summary summary summary summary summary summary summary summary summary summary statement statement statement statement statement statement statement statement statement statement statement statement form, along with brief 

discussion points on NASA applicability. Three themes emerge discussion discussion discussion discussion discussion discussion discussion discussion discussion discussion discussion points on NASA applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability. Three themes emerge 

from these discussion points as shown above.

8.3 DISCUSSION ISCUSSION

The core themes of the recommendations and fi ndings deal with The core themes of the recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations and findings deal with 

the structural/organizational checks-and-balances of technical the structural/or structural/or structural/or structural/or structural/or structural/or structural/or structural/or structural/or structural/or structural/or structural/organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational checks-and-balances checks-and-balances checks-and-balances checks-and-balances checks-and-balances checks-and-balances checks-and-balances checks-and-balances checks-and-balances checks-and-balances checks-and-balances checks-and-balances of technical technical technical technical technical technical technical technical technical technical technical technical 

and safety decisions and the associated mitigation of program and safety decisions decisions decisions decisions decisions decisions decisions decisions decisions decisions decisions and the associated associated associated associated associated associated associated associated associated associated associated mitigation mitigation mitigation mitigation mitigation mitigation mitigation mitigation mitigation mitigation mitigation of program program program program program program program program program program program 

risks. The “checks-and-balances” term has been used broadly risks. The “checks-and-balances” “checks-and-balances” “checks-and-balances” “checks-and-balances” “checks-and-balances” “checks-and-balances” “checks-and-balances” “checks-and-balances” “checks-and-balances” “checks-and-balances” “checks-and-balances” term has been used broadly broadly broadly broadly broadly broadly broadly broadly broadly broadly broadly 

throughout NASA to describe the principle of multiple avenues throughout throughout throughout throughout throughout throughout throughout throughout throughout throughout throughout NASA to describe describe describe describe describe describe describe describe describe describe describe the principle principle principle principle principle principle principle principle principle principle principle of multiple multiple multiple multiple multiple multiple multiple multiple multiple multiple multiple avenues avenues avenues avenues avenues avenues avenues avenues avenues avenues avenues 

to independently reach key technical and operational deci- to independently independently independently independently independently independently independently independently independently independently independently reach key technical technical technical technical technical technical technical technical technical technical technical and operational operational operational operational operational operational operational operational operational operational operational decisions relating to program safety and mission success. The term sions relating relating relating relating relating relating relating relating relating relating relating relating to program program program program program program program program program program program program safety and mission mission mission mission mission mission mission mission mission mission mission mission success. success. success. success. success. success. success. success. success. success. success. success. The term 

“checks” usually implies a seconding of responsibility in review- “checks” “checks” “checks” “checks” “checks” “checks” “checks” “checks” “checks” “checks” “checks” usually usually usually usually usually usually usually usually usually usually usually implies implies implies implies implies implies implies implies implies implies implies a seconding seconding seconding seconding seconding seconding seconding seconding seconding seconding seconding of responsibility responsibility responsibility responsibility responsibility responsibility responsibility responsibility responsibility responsibility responsibility in review- review- review- review- review- review- review- review- review- review- reviewing or making program decisions. The term “balances” typically ing or making program program program program program program program program program program program program decisions. decisions. decisions. decisions. decisions. decisions. decisions. decisions. decisions. decisions. decisions. decisions. The term “balances” “balances” “balances” “balances” “balances” “balances” “balances” “balances” “balances” “balances” “balances” “balances” typically typically typically typically typically typically typically typically typically typically typically typically 

means the appropriate spread of authority among multiple orga- means the appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate spread of authority authority authority authority authority authority authority authority authority authority authority among multiple multiple multiple multiple multiple multiple multiple multiple multiple multiple multiple organizational elements. As highlighted by CAIB Board Chairman nizational nizational nizational nizational nizational nizational nizational nizational nizational nizational nizational nizational elements. elements. elements. elements. elements. elements. elements. elements. elements. elements. elements. elements. As highlighted highlighted highlighted highlighted highlighted highlighted highlighted highlighted highlighted highlighted highlighted highlighted by CAIB Board Chairman Chairman Chairman Chairman Chairman Chairman Chairman Chairman Chairman Chairman Chairman Chairman 

Admiral Gehman in testimony to Congress, NASA appeared to Admiral Admiral Admiral Admiral Admiral Admiral Admiral Admiral Admiral Admiral Admiral Gehman in testimony testimony testimony testimony testimony testimony testimony testimony testimony testimony testimony to Congress, Congress, Congress, Congress, Congress, Congress, Congress, Congress, Congress, Congress, Congress, NASA appeared appeared appeared appeared appeared appeared appeared appeared appeared appeared appeared to 

be “ill-served by an imperfect system of checks-and-balances.” be “ill-served “ill-served “ill-served “ill-served “ill-served “ill-served “ill-served “ill-served “ill-served “ill-served “ill-served by an imperfect imperfect imperfect imperfect imperfect imperfect imperfect imperfect imperfect imperfect imperfect system of checks-and-balances.” checks-and-balances.” checks-and-balances.” checks-and-balances.” checks-and-balances.” checks-and-balances.” checks-and-balances.” checks-and-balances.” checks-and-balances.” checks-and-balances.” checks-and-balances.” 

In the Shuttle case, it was observed by the CAIB that engineering In the Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle case, it was observed observed observed observed observed observed observed observed observed observed observed observed by the CAIB that engineering engineering engineering engineering engineering engineering engineering engineering engineering engineering engineering engineering 

specialists could not effectively offer independent and balanced specialists specialists specialists specialists specialists specialists specialists specialists specialists specialists specialists could not effectively fectively fectively fectively fectively fectively fectively fectively fectively fectively fectively offer independent independent independent independent independent independent independent independent independent independent independent and balanced balanced balanced balanced balanced balanced balanced balanced balanced balanced balanced 

views because their position in the organizational structure was views because because because because because because because because because because their position position position position position position position position position position in the organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational structure structure structure structure structure structure structure structure structure structure was 

embedded in the program. In another example, the checks of the embedded embedded embedded embedded embedded embedded embedded embedded embedded embedded embedded in the program. program. program. program. program. program. program. program. program. program. program. In another another another another another another another another another another another example, example, example, example, example, example, example, example, example, example, example, the checks of the 

safety offi ce had inadequate resources, even though, according to safety office had inadequate inadequate inadequate inadequate inadequate inadequate inadequate inadequate inadequate inadequate resources, resources, resources, resources, resources, resources, resources, resources, resources, resources, even though, though, though, though, though, though, though, though, though, though, according according according according according according according according according according to 

Gehman, the “safety offi ce was, on paper, perfect.” Gehman, the “safety office was, on paper, perfect.” 

With a clear mandate to address the “ill-perfect” and under- With a clear mandate mandate mandate mandate mandate mandate mandate mandate mandate mandate mandate to address address address address address address address address address address address the “ill-perfect” “ill-perfect” “ill-perfect” “ill-perfect” “ill-perfect” “ill-perfect” “ill-perfect” “ill-perfect” “ill-perfect” “ill-perfect” “ill-perfect” and underresourced check-and-balance system within NASA, the CAIB resourced resourced resourced resourced resourced resourced resourced resourced resourced resourced check-and-balance check-and-balance check-and-balance check-and-balance check-and-balance check-and-balance check-and-balance check-and-balance check-and-balance check-and-balance system within NASA, the CAIB 

recommended an Independent Technical Engineering Authority recommended recommended recommended recommended recommended recommended recommended recommended recommended recommended an Independent Independent Independent Independent Independent Independent Independent Independent Independent Independent Technical echnical echnical echnical echnical echnical echnical echnical echnical echnical Engineering Engineering Engineering Engineering Engineering Engineering Engineering Engineering Engineering Engineering Authority Authority Authority Authority Authority Authority Authority Authority Authority Authority 

(ITEA) be created as a new key structural component within (ITEA) be created created created created created created created created created created created as a new key structural structural structural structural structural structural structural structural structural structural structural component component component component component component component component component component component within 

NASA for the Space Shuttle Program. The specifi c authority and NASA for the Space Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Program. Program. Program. Program. Program. Program. Program. Program. Program. Program. The specifi specic authority authority authority authority authority authority authority authority authority authority and 

responsibilities of that ITEA must be developed in accordance responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities of that ITEA must be developed developed developed developed developed developed developed developed developed developed developed in accordance accordance accordance accordance accordance accordance accordance accordance accordance accordance accordance 

with the CAIB (CAIB R7.5-1). The CAIB also recommended with the CAIB (CAIB R7.5-1). R7.5-1). R7.5-1). R7.5-1). R7.5-1). R7.5-1). R7.5-1). R7.5-1). R7.5-1). R7.5-1). The CAIB also recommended recommended recommended recommended recommended recommended recommended recommended recommended recommended 

that the NASA Headquarters Offi ce of Safety and Mission As- that the NASA Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Office of Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Assurance should have a direct line authority over the entire Space surance surance surance surance surance surance surance surance surance surance should have a direct line authority authority authority authority authority authority authority authority authority authority over the entire Space 

Shuttle Program safety organization and should be independently Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Program Program Program Program Program Program Program Program Program Program safety organization ganization ganization ganization ganization ganization ganization ganization ganization ganization and should be independently independently independently independently independently independently independently independently independently independently 

resourced (CAIB R7.5-2). The Diaz Team concluded that these resourced resourced resourced resourced resourced resourced resourced resourced resourced resourced (CAIB R7.5-2). R7.5-2). R7.5-2). R7.5-2). R7.5-2). R7.5-2). R7.5-2). R7.5-2). R7.5-2). R7.5-2). The Diaz Team concluded concluded concluded concluded concluded concluded concluded concluded concluded concluded that these 

concepts could be effectively applied to provide independent concepts concepts concepts concepts concepts concepts concepts concepts concepts concepts could be effectively fectively fectively fectively fectively fectively fectively fectively fectively fectively applied applied applied applied applied applied applied applied applied applied to provide provide provide provide provide provide provide provide provide provide independent independent independent independent independent independent independent independent independent independent 

engineering and safety across all NASA programs. Therefore, engineering engineering engineering engineering engineering engineering engineering engineering engineering engineering engineering and safety across all NASA programs. programs. programs. programs. programs. programs. programs. programs. programs. programs. programs. Therefore, Therefore, Therefore, Therefore, Therefore, Therefore, Therefore, Therefore, Therefore, Therefore, Therefore, 

the Team recommends that an independent technical engineering the Team recommends recommends recommends recommends recommends recommends recommends recommends recommends recommends that an independent independent independent independent independent independent independent independent independent independent technical technical technical technical technical technical technical technical technical technical engineering engineering engineering engineering engineering engineering engineering engineering engineering engineering 

authority concept be implemented for all programs. All programs authority authority authority authority authority authority authority authority authority authority authority concept concept concept concept concept concept concept concept concept concept concept be implemented implemented implemented implemented implemented implemented implemented implemented implemented implemented implemented for all programs. programs. programs. programs. programs. programs. programs. programs. programs. programs. programs. All programs programs programs programs programs programs programs programs programs programs programs 

will benefi t from an independent engineering authority to ensure will benefit from an independent independent independent independent independent independent independent independent independent independent engineering engineering engineering engineering engineering engineering engineering engineering engineering engineering authority authority authority authority authority authority authority authority authority authority to ensure 

that technical standards are being met. This approach will also that technical technical technical technical technical technical technical technical technical technical technical standards standards standards standards standards standards standards standards standards standards standards are being met. This approach approach approach approach approach approach approach approach approach approach approach will also 

provide all programs with appropriate processes and channels to provide provide provide provide provide provide provide provide provide provide all programs programs programs programs programs programs programs programs programs programs with appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate processes processes processes processes processes processes processes processes processes processes and channels channels channels channels channels channels channels channels channels channels to 

ensure that any waivers of requirements and technical standards ensure that any waivers waivers waivers waivers waivers waivers waivers waivers waivers waivers of requirements requirements requirements requirements requirements requirements requirements requirements requirements requirements and technical technical technical technical technical technical technical technical technical technical standards standards standards standards standards standards standards standards standards standards 

are done so only with the review and approval of an appropriate are done so only with the review and approval approval approval approval approval approval approval approval approval approval approval of an appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate 

engineering authority. engineering authority. 

The adopted organization concept must, at a minimum, develop The adopted organization concept must, at a minimum, develop

and maintain, and be the sole waiver-granting authority for all and maintain, and be the sole waiver-granting authority for all

technical standards; conduct trend and risk analyses and own the technical standards; conduct trend and risk analyses and own the

failure mode, effects analyses and hazard reporting systems; and failure mode, effects analyses and hazard reporting systems; and

decide what is and what is not an anomalous event. All projects decide what is and what is not an anomalous event. All projects

and programs will benefi t from these functions being consistently and programs will benefit from these functions being consistently

applied. This approach creates the system of checks-and-balances applied. This approach createsthe system of checks-and-balances

to ensure sound and knowledge-based decision-making. NASA to ensure sound and knowledge-based decision-making. NASA

will develop specifi c structural relationships among the Program will develop specific structural relationships among the Program

Offi ces, the NASA Engineering and Safety Center (NESC), and Offices, the NASA Engineering and Safety Center (NESC), and

future ITEA implementations to facilitate communication, reduce future ITEAimplementationsto facilitate communication, reduce

program safety risks, and assure mission success. program safety risks, and assure mission success.

The feedback from Safety and Mission Success Week reinforced The feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback from Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Success Success Success Success Success Success Success Success Success Success Week reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced 

the Diaz Team assessment: the Diaz Team assessment:

» NASA should look to eliminate or modify organi- NASA should look to eliminate or modify organizational distinctions that create divisions within the 

Agency, which potentially foster competition rather Agency, which potentially foster competition rather 

than collaboration.

» Clearly defi ne roles, responsibilities, and accountabil- Clearly define roles, responsibilities, and accountability starting with the role of the Agency/Center, then ity starting with the role of the Agency/Center, then 

on down, to describe strategically what we want to do, 

who will do it, and who is responsible for what. 
4 3
4 4

» Have our leadership thoroughly evaluate the system of 

safety and mission success with regard to the plethora 

of organizations having responsibility for oversee- of organizations having responsibility for overseeing the safety and quality of work performed with the 

express intent of making it simpler, safer, and higher express intent of making it simpler, safer, and higher 

quality/reliability while reducing the overlapping 

responsibilities.

» Organizations must be structured to provide a more Organizations must be structured to provide a more 

effective balance between program schedule/cost man- effective balance between program schedule/cost management and technical review authority. agement and technical review authority.

The CAIB R-O-Fs also addressed the complexities of NASA The CAIB R-O-Fs also addressed addressed addressed addressed addressed addressed addressed addressed addressed addressed addressed addressed the complexities complexities complexities complexities complexities complexities complexities complexities complexities complexities complexities complexities of NASA

as an organization and the real and perceived barriers that ex- as an organization ganization ganization ganization ganization ganization ganization ganization ganization ganization ganization and the real and perceived perceived perceived perceived perceived perceived perceived perceived perceived perceived perceived barriers barriers barriers barriers barriers barriers barriers barriers barriers barriers barriers that exist which inhibit communication and effective decision-making. ist which inhibit inhibit inhibit inhibit inhibit inhibit inhibit inhibit inhibit inhibit inhibit inhibit communication communication communication communication communication communication communication communication communication communication communication communication and effective fective fective fective fective fective fective fective fective fective fective fective decision-making. decision-making. decision-making. decision-making. decision-making. decision-making. decision-making. decision-making. decision-making. decision-making. decision-making. decision-making. 

While the CAIB was not prescriptive in its approach, it offered While the CAIB was not prescriptive prescriptive prescriptive prescriptive prescriptive prescriptive prescriptive prescriptive prescriptive prescriptive prescriptive in its approach, approach, approach, approach, approach, approach, approach, approach, approach, approach, approach, it offered 

the Diaz Team insights regarding the organizational characteris- the Diaz Team insights insights insights insights insights insights insights insights insights insights insights insights regarding regarding regarding regarding regarding regarding regarding regarding regarding regarding regarding regarding the organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational characteris- characteris- characteris- characteris- characteris- characteris- characteris- characteris- characteris- characteris- characteris- characteristics NASA should strive to achieve. These include: tics NASA should strive to achieve. These include: 

• Effective teamwork exists across boundaries with Effective teamwork exists across boundaries with 

strong communication links. 

• People deliver results, not tasks.

• Every member of the workforce is empowered and 

willing to offer alternate points of view. willing to offer alternate points of view.

• Organizational functions are well defi ned and under- Organizational functions are well defined and understood.

• Roles of authority, accountability, and responsibility Roles of authority, accountability, and responsibility 

are precisely defi ned and widely understood. are precisely defined and widely understood.

An effective organizational structure that implements NASA An effective fective fective fective fective fective fective fective fective fective fective organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational structure structure structure structure structure structure structure structure structure structure structure that implements implements implements implements implements implements implements implements implements implements implements NASA

strategies and programs, while minimizing built-in barriers, is strategies strategies strategies strategies strategies strategies strategies strategies strategies strategies strategies strategies and programs, programs, programs, programs, programs, programs, programs, programs, programs, programs, programs, programs, while minimizing minimizing minimizing minimizing minimizing minimizing minimizing minimizing minimizing minimizing minimizing minimizing built-in built-in built-in built-in built-in built-in built-in built-in built-in built-in built-in built-in barriers, barriers, barriers, barriers, barriers, barriers, barriers, barriers, barriers, barriers, barriers, barriers, is 

appropriate and necessary. The organization must foster the shar- appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate and necessary necessary necessary necessary necessary necessary necessary necessary necessary necessary necessary. The organization ganization ganization ganization ganization ganization ganization ganization ganization ganization ganization must foster the sharing of knowledge and data and facilitate communication based ing of knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge knowledge and data and facilitate facilitate facilitate facilitate facilitate facilitate facilitate facilitate facilitate facilitate facilitate facilitate communication communication communication communication communication communication communication communication communication communication communication communication based 

upon a consistency of information and knowledge structures. 

The structure of an organization should help clarify roles and The structure structure structure structure structure structure structure structure structure structure structure structure of an organization ganization ganization ganization ganization ganization ganization ganization ganization ganization ganization ganization should help clarify clarify clarify clarify clarify clarify clarify clarify clarify clarify clarify clarify roles and 

responsibilities of individual employees, work groups, and responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities of individual individual individual individual individual individual individual individual individual individual individual employees, employees, employees, employees, employees, employees, employees, employees, employees, employees, employees, work groups, groups, groups, groups, groups, groups, groups, groups, groups, groups, groups, and 

leadership. The Diaz Team is not prescribing one organizational leadership. leadership. leadership. leadership. leadership. leadership. leadership. leadership. leadership. leadership. leadership. leadership. The Diaz Team is not prescribing prescribing prescribing prescribing prescribing prescribing prescribing prescribing prescribing prescribing prescribing prescribing one organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational 

structure over another, but the Team believes for NASA to suc- structure structure structure structure structure structure structure structure structure structure structure over another another another another another another another another another another another, but the Team believes believes believes believes believes believes believes believes believes believes believes for NASA to succeed with any new organization, every member of the workforce ceed with any new organization, ganization, ganization, ganization, ganization, ganization, ganization, ganization, ganization, ganization, ganization, ganization, every member of the workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce 

should be able to answer three basic questions:

• Do you know where you fi t into the organizational Do you know where you fit into the organizational 

structure?

• Do you know whom you report to, and who reports to 

you?

• Do you know your responsibility, authority, and ac- Do you know your responsibility, authority, and accountability?

If NASAʼs workforce cannot answer these three basic questions, If NASAʼs workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce cannot answer these three basic questions, questions, questions, questions, questions, questions, questions, questions, questions, questions, questions, 

the organization is dysfunctional and ultimately the entire orga- the organization ganization ganization ganization ganization ganization ganization ganization ganization ganization ganization is dysfunctional dysfunctional dysfunctional dysfunctional dysfunctional dysfunctional dysfunctional dysfunctional dysfunctional dysfunctional dysfunctional and ultimately ultimately ultimately ultimately ultimately ultimately ultimately ultimately ultimately ultimately ultimately the entire organization will suffer. nization will suffer. 

Poor organizational structure can cause highly talented and Poor organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational structure structure structure structure structure structure structure structure structure structure structure structure can cause highly talented talented talented talented talented talented talented talented talented talented talented talented and 

skilled people to fail. Pushing people to work harder or replac- skilled skilled skilled skilled skilled skilled skilled skilled skilled skilled people to fail. Pushing Pushing Pushing Pushing Pushing Pushing Pushing Pushing Pushing Pushing people to work harder or replac- replac- replac- replac- replac- replac- replac- replac- replac- replacing a few managers will not change the cultural biases within ing a few managers managers managers managers managers managers managers managers managers managers will not change the cultural cultural cultural cultural cultural cultural cultural cultural cultural cultural biases within 

NASAʼs organizational structure. NASAʼs organizational structure. 

Organizational structure alone does not create a healthy orga- Organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational structure structure structure structure structure structure structure structure structure structure structure alone does not create a healthy healthy healthy healthy healthy healthy healthy healthy healthy healthy healthy organizational environment. Effective organizational leadership and nizational nizational nizational nizational nizational nizational nizational nizational nizational nizational environment. environment. environment. environment. environment. environment. environment. environment. environment. environment. Effective fective fective fective fective fective fective fective fective fective organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational leadership leadership leadership leadership leadership leadership leadership leadership leadership leadership and 

discipline are necessary. During Safety and Mission Success discipline discipline discipline discipline discipline discipline discipline discipline discipline discipline discipline are necessary necessary necessary necessary necessary necessary necessary necessary necessary necessary necessary. During Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Success Success Success Success Success Success Success Success Success Success Success 

Week, individuals highlighted several organizational issues of Week, individuals individuals individuals individuals individuals individuals individuals individuals individuals individuals highlighted highlighted highlighted highlighted highlighted highlighted highlighted highlighted highlighted highlighted several several several several several several several several several several organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational issues of 

concern across NASA Centers that need to be addressed. These concern concern concern concern concern concern concern concern concern concern across NASA Centers Centers Centers Centers Centers Centers Centers Centers Centers Centers that need to be addressed. addressed. addressed. addressed. addressed. addressed. addressed. addressed. addressed. addressed. These 

included ensuring positions are fi lled with qualifi ed people, clari- included included included included included included included included included included included ensuring ensuring ensuring ensuring ensuring ensuring ensuring ensuring ensuring ensuring ensuring positions positions positions positions positions positions positions positions positions positions positions are filled with qualifi qualied people, people, people, people, people, people, people, people, people, people, people, clarifying roles and responsibilities with clear lines of authority, hold- fying roles and responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities responsibilities with clear lines of authority authority authority authority authority authority authority authority authority authority, holding people accountable, facilitating effective communication and ing people accountable, accountable, accountable, accountable, accountable, accountable, accountable, accountable, accountable, accountable, accountable, facilitating facilitating facilitating facilitating facilitating facilitating facilitating facilitating facilitating facilitating facilitating effective fective fective fective fective fective fective fective fective fective fective communication communication communication communication communication communication communication communication communication communication communication and 

decision-making, and increasing the level of technical expertise. decision-making, decision-making, decision-making, decision-making, decision-making, decision-making, decision-making, decision-making, decision-making, decision-making, and increasing increasing increasing increasing increasing increasing increasing increasing increasing increasing the level of technical technical technical technical technical technical technical technical technical technical expertise. expertise. expertise. expertise. expertise. expertise. expertise. expertise. expertise. expertise. 

The solutions to many of these issues require a multi-faceted ap- The solutions solutions solutions solutions solutions solutions solutions solutions solutions solutions solutions to many of these issues require require require require require require require require require require require a multi-faceted multi-faceted multi-faceted multi-faceted multi-faceted multi-faceted multi-faceted multi-faceted multi-faceted multi-faceted multi-faceted approach, incorporating organizational structure changes, process proach, proach, proach, proach, proach, proach, proach, proach, proach, proach, incorporating incorporating incorporating incorporating incorporating incorporating incorporating incorporating incorporating incorporating organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational structure structure structure structure structure structure structure structure structure structure changes, changes, changes, changes, changes, changes, changes, changes, changes, changes, process process process process process process process process process process 

changes, and changes in management and career development changes, changes, changes, changes, changes, changes, changes, changes, changes, changes, changes, and changes changes changes changes changes changes changes changes changes changes changes in management management management management management management management management management management management and career development development development development development development development development development development development 

practices. 

It is essential that we also promote an understanding of program It is essential essential essential essential essential essential essential essential essential essential essential that we also promote promote promote promote promote promote promote promote promote promote promote an understanding understanding understanding understanding understanding understanding understanding understanding understanding understanding understanding of program program program program program program program program program program program 

interdependencies and implications of management decisions interdependencies interdependencies interdependencies interdependencies interdependencies interdependencies interdependencies interdependencies interdependencies interdependencies and implications implications implications implications implications implications implications implications implications implications of management management management management management management management management management management decisions decisions decisions decisions decisions decisions decisions decisions decisions decisions 

across programs. Appropriate communications channels across across programs. programs. programs. programs. programs. programs. programs. programs. programs. programs. programs. Appropriate Appropriate Appropriate Appropriate Appropriate Appropriate Appropriate Appropriate Appropriate Appropriate Appropriate communications communications communications communications communications communications communications communications communications communications communications channels channels channels channels channels channels channels channels channels channels channels across 

organizational elements will help prevent creation of isolated organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational elements elements elements elements elements elements elements elements elements elements will help prevent prevent prevent prevent prevent prevent prevent prevent prevent prevent creation creation creation creation creation creation creation creation creation creation of isolated isolated isolated isolated isolated isolated isolated isolated isolated isolated 

islands of information. Developing process-oriented models islands islands islands islands islands islands islands islands islands islands islands of information. information. information. information. information. information. information. information. information. information. information. Developing Developing Developing Developing Developing Developing Developing Developing Developing Developing Developing process-oriented process-oriented process-oriented process-oriented process-oriented process-oriented process-oriented process-oriented process-oriented process-oriented process-oriented models 

and information systems, as well as engineering capabilities and and information information information information information information information information information information systems, systems, systems, systems, systems, systems, systems, systems, systems, systems, as well as engineering engineering engineering engineering engineering engineering engineering engineering engineering engineering capabilities capabilities capabilities capabilities capabilities capabilities capabilities capabilities capabilities capabilities and 

tools to facilitate effective sharing of information and data across tools to facilitate facilitate facilitate facilitate facilitate facilitate facilitate facilitate facilitate facilitate effective fective fective fective fective fective fective fective fective fective sharing sharing sharing sharing sharing sharing sharing sharing sharing sharing of information information information information information information information information information information and data across 

programs will also greatly enhance collaboration and improve programs programs programs programs programs programs programs programs programs programs will also greatly greatly greatly greatly greatly greatly greatly greatly greatly greatly enhance enhance enhance enhance enhance enhance enhance enhance enhance enhance collaboration collaboration collaboration collaboration collaboration collaboration collaboration collaboration collaboration collaboration and improve improve improve improve improve improve improve improve improve improve 

communication and decision-making NASA-wide. 

All elements of NASAʼs organizational structure involve the All elements elements elements elements elements elements elements elements elements elements of NASAʼs organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational structure structure structure structure structure structure structure structure structure structure involve involve involve involve involve involve involve involve involve involve the 

management and accounting of resources. With the implemen- management management management management management management management management management management management and accounting accounting accounting accounting accounting accounting accounting accounting accounting accounting accounting of resources. resources. resources. resources. resources. resources. resources. resources. resources. resources. resources. With the implemen- implemen- implemen- implemen- implemen- implemen- implemen- implemen- implemen- implemen- implementation of full-cost accounting in the Agency, it is important that tation of full-cost full-cost full-cost full-cost full-cost full-cost full-cost full-cost full-cost full-cost accounting accounting accounting accounting accounting accounting accounting accounting accounting accounting in the Agency, it is important important important important important important important important important important that 

NASA employees and contractors comprehend the implications NASA employees employees employees employees employees employees employees employees employees employees employees and contractors contractors contractors contractors contractors contractors contractors contractors contractors contractors contractors comprehend comprehend comprehend comprehend comprehend comprehend comprehend comprehend comprehend comprehend comprehend the implications implications implications implications implications implications implications implications implications implications implications 

of this method of accounting within programs. Full cost account- of this method of accounting accounting accounting accounting accounting accounting accounting accounting accounting accounting within programs. programs. programs. programs. programs. programs. programs. programs. programs. programs. Full cost account- account- account- account- account- account- account- account- account- accounting will provide metrics that have not previously been available. ing will provide provide provide provide provide provide provide provide provide provide metrics metrics metrics metrics metrics metrics metrics metrics metrics metrics that have not previously previously previously previously previously previously previously previously previously previously been available. available. available. available. available. available. available. available. available. available. 

The use of these metrics must be integrated into a technical-cost- The use of these metrics metrics metrics metrics metrics metrics metrics metrics metrics metrics metrics must be integrated integrated integrated integrated integrated integrated integrated integrated integrated integrated integrated into a technical-cost- technical-cost- technical-cost- technical-cost- technical-cost- technical-cost- technical-cost- technical-cost- technical-cost- technical-cost- technical-costschedule integrated system. Full cost accounting principles are schedule schedule schedule schedule schedule schedule schedule schedule schedule schedule integrated integrated integrated integrated integrated integrated integrated integrated integrated integrated system. system. system. system. system. system. system. system. system. system. Full cost accounting accounting accounting accounting accounting accounting accounting accounting accounting accounting principles principles principles principles principles principles principles principles principles principles are 

part of a disciplined organizational management approach, but if part of a disciplined disciplined disciplined disciplined disciplined disciplined disciplined disciplined disciplined disciplined disciplined organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational management management management management management management management management management management management approach, approach, approach, approach, approach, approach, approach, approach, approach, approach, approach, but if 

used without a balanced consideration of technical, schedule, and used without without without without without without without without without without a balanced balanced balanced balanced balanced balanced balanced balanced balanced balanced consideration consideration consideration consideration consideration consideration consideration consideration consideration consideration of technical, technical, technical, technical, technical, technical, technical, technical, technical, technical, schedule, schedule, schedule, schedule, schedule, schedule, schedule, schedule, schedule, schedule, and 

strategic concerns the management system will be degraded. 

In summary, a healthy organizational structure is a solid founda- In summary summary summary summary summary summary summary summary summary summary summary, a healthy healthy healthy healthy healthy healthy healthy healthy healthy healthy healthy organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational structure structure structure structure structure structure structure structure structure structure structure is a solid founda- founda- founda- founda- founda- founda- founda- founda- founda- founda- foundation to help enable our people to succeed. NASA now has the tion to help enable our people to succeed. succeed. succeed. succeed. succeed. succeed. succeed. succeed. succeed. succeed. NASA now has the 

opportunity to examine its organizational structure and rede- opportunity opportunity opportunity opportunity opportunity opportunity opportunity opportunity opportunity opportunity to examine examine examine examine examine examine examine examine examine examine its organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational structure structure structure structure structure structure structure structure structure structure and redesign or create new organizational elements that are inherently sign or create new organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational elements elements elements elements elements elements elements elements elements elements elements that are inherently inherently inherently inherently inherently inherently inherently inherently inherently inherently inherently 

healthier and succeed in creating the proper checks-and-balances healthier healthier healthier healthier healthier healthier healthier healthier healthier healthier and succeed succeed succeed succeed succeed succeed succeed succeed succeed succeed in creating creating creating creating creating creating creating creating creating creating the proper checks-and-balances checks-and-balances checks-and-balances checks-and-balances checks-and-balances checks-and-balances checks-and-balances checks-and-balances checks-and-balances checks-and-balances 

and chains of accountability to enable effective communication and chains of accountability accountability accountability accountability accountability accountability accountability accountability accountability accountability accountability to enable effective fective fective fective fective fective fective fective fective fective fective communication communication communication communication communication communication communication communication communication communication communication 

and decision-making. Through effective and disciplined organi- and decision-making. decision-making. decision-making. decision-making. decision-making. decision-making. decision-making. decision-making. decision-making. decision-making. Through Through Through Through Through Through Through Through Through Through effective fective fective fective fective fective fective fective fective fective and disciplined disciplined disciplined disciplined disciplined disciplined disciplined disciplined disciplined disciplined organizational leadership, NASA can increase safety, manage risk, and zational zational zational zational zational zational zational zational zational zational zational leadership, leadership, leadership, leadership, leadership, leadership, leadership, leadership, leadership, leadership, leadership, NASA can increase increase increase increase increase increase increase increase increase increase increase safety, manage risk, and 

achieve program and mission success throughout the Agency. achieve program and mission success throughout the Agency. 

In addition to the actions in the Diaz Team Matrix that address In addition addition addition addition addition addition addition addition addition addition to the actions actions actions actions actions actions actions actions actions actions in the Diaz Team Matrix that address address address address address address address address address address 

each R-O-F, the Diaz Team has one goal addressing the Organi- each R-O-F, the Diaz Team has one goal addressing addressing addressing addressing addressing addressing addressing addressing addressing addressing the Organizational Structure category, as shown in Table 20. zational Structure category, as shown in Table 20.

Table 20. The Diaz Team developed one goal for Organizational Structure.

Organizational Structure – Diaz Team Goal

The Agency should complete its current NASA-wide assessment and establish independent technical authority.
4 5

Table 21. The Diaz Team determined that three Recommendations and 10 Findings could be included in the Organizational Structure 

Category, resulting in four actions.

Diaz 

Team # CAIB # CAIB Report Recommendations and Pertinent Factors Diaz Team Discussion Action # Responsibility

R23 R7.5-1 Establish Independent Technical and 

Engineering Authority

All programs can benefi t from independent 

authority 9 Q

R24 R7.5-2 HQ S&MA have direct line authority over Shuttle 

safety

Independent safety organization for all major 

programs

9 Q

R26 R9.1-1 Prepare detailed plan for ITEA, safety offi ce, 

integration offi ce Create orderly transition process 9 Q

F57 F6.1-2 Foam shedding safety concerns evolved to “in 

family”

Independent organization should review 

deviations 27 AE

F61 F6.1-6 Debris shedding classifi ed as In-Flight Anomaly Independent organization should review 

deviations 27 AE

F68 F6.2-2 Shuttle and ISS intertwining increase scheduling 

complexity

Manage programs from an Agency-wide 

perspective 31 AE

F105 F7.1-1 NASA has struggled to achieve viable safety 

programs 

Audit staffi ng practices and workforce 

management 9 Q

F107 F7.4-2 S&MA dependent on program for funding Need to identify confl icts of interest and 

dependencies 9 Q

F109 F7.4-4 System safety engineering separated from 

mainstream 

Review Agency-wide integration of safety 

engineering 9 Q

F111 F7.4-6 Shuttle Integration Offi ce does not handle Orbiter Clear organizational responsibilities needed 37 AE

F113 F7.4-8 Foam responsibilities inconsistent within 

Integration offi ce

Programs need clear authority and 

responsibilities 37 AE

F117 F7.4-12 Dependence of SR&QA limits ability to report 

problems Identify internal confl icts of interest 9 Q

F118 F7.4-13 Confl icting roles and responsibilities in safety 

program Identify internal confl icts of interest 9 Q
4 6

9.0 RISK MANAGEMENT

NASA fails to account for program risk.

Agency-wide Themes

• NASA must establish a consistent set of risk assessment tools, applied in a uniform way, across 

all programs.

• NASA management must have a clear understanding of safety requirements and risks associated with key decisions.

• NASA must stop accepting increasing levels of 

risk without understanding the total program risk.

9.1 INTRODUCTION NTRODUCTION

This section looks at key issues of risk management and the This section section section section section section section section section section section looks at key issues of risk management management management management management management management management management management management and the 

lessons that can be drawn from the loss of lessons lessons lessons lessons lessons lessons lessons that can be drawn from the loss of Columbia. Included 

in risk management are NASAʼs safety programs for its human- in risk management management management management management management management management management management management are NASAʼs safety programs programs programs programs programs programs programs programs programs programs programs for its humanrated missions, industrial safety, public safety, and assessing rated missions, missions, missions, missions, missions, missions, missions, missions, missions, missions, missions, industrial industrial industrial industrial industrial industrial industrial industrial industrial industrial industrial safety, public safety, and assessing assessing assessing assessing assessing assessing assessing assessing assessing assessing assessing 

and evaluating risks for successful implementation of all NASA and evaluating evaluating evaluating evaluating evaluating evaluating evaluating evaluating evaluating evaluating evaluating evaluating risks for successful successful successful successful successful successful successful successful successful successful successful successful implementation implementation implementation implementation implementation implementation implementation implementation implementation implementation implementation implementation of all NASA

programs. 

A fundamental tenet of NASA programs, displayed throughout A fundamental fundamental fundamental fundamental fundamental fundamental fundamental fundamental fundamental fundamental fundamental tenet of NASA programs, programs, programs, programs, programs, programs, programs, programs, programs, programs, programs, displayed displayed displayed displayed displayed displayed displayed displayed displayed displayed displayed throughout throughout throughout throughout throughout throughout throughout throughout throughout throughout throughout 

all fi eld Centers and contractor facilities, is safety and mission all field Centers Centers Centers Centers Centers Centers Centers Centers Centers Centers Centers Centers and contractor contractor contractor contractor contractor contractor contractor contractor contractor contractor contractor contractor facilities, facilities, facilities, facilities, facilities, facilities, facilities, facilities, facilities, facilities, facilities, facilities, is safety and mission mission mission mission mission mission mission mission mission mission mission mission 

assurance. Stellar safety records, such as in the Navy Nuclear assurance. assurance. assurance. assurance. assurance. assurance. assurance. assurance. assurance. assurance. assurance. Stellar Stellar Stellar Stellar Stellar Stellar Stellar Stellar Stellar Stellar Stellar safety records, records, records, records, records, records, records, records, records, records, records, such as in the Navy Nuclear Nuclear Nuclear Nuclear Nuclear Nuclear Nuclear Nuclear Nuclear Nuclear Nuclear 

Reactor Program, involve applying the most modern risk man- Reactor Reactor Reactor Reactor Reactor Reactor Reactor Reactor Reactor Reactor Reactor Program, Program, Program, Program, Program, Program, Program, Program, Program, Program, Program, involve involve involve involve involve involve involve involve involve involve involve applying applying applying applying applying applying applying applying applying applying applying the most modern risk management techniques to a complex system that must operate over agement agement agement agement agement agement agement agement agement agement agement agement techniques techniques techniques techniques techniques techniques techniques techniques techniques techniques techniques techniques to a complex complex complex complex complex complex complex complex complex complex complex complex system that must operate operate operate operate operate operate operate operate operate operate operate operate over 

a wide environmental range successfully for many years. Yet, for a wide environmental environmental environmental environmental environmental environmental environmental environmental environmental environmental environmental range successfully successfully successfully successfully successfully successfully successfully successfully successfully successfully successfully for many years. Yet, for 

all its decades of efforts managing inherently risky spacefl ight all its decades decades decades decades decades decades decades decades decades decades decades decades of efforts managing managing managing managing managing managing managing managing managing managing managing managing inherently inherently inherently inherently inherently inherently inherently inherently inherently inherently inherently inherently risky spacefl spaceight 

activities, NASAʼs organization and risk management processes activities, activities, activities, activities, activities, activities, activities, activities, activities, activities, activities, NASAʼs organization ganization ganization ganization ganization ganization ganization ganization ganization ganization ganization and risk management management management management management management management management management management management processes processes processes processes processes processes processes processes processes processes processes 

failed in the losses of failed in the losses of Challenger and Columbia. Ultimately, the . Ultimately, the 

CAIB found a Shuttle Program history of increasing risk. 

Where did the increasing risks come from? According to the Where did the increasing increasing increasing increasing increasing increasing increasing increasing increasing increasing increasing risks come from? According According According According According According According According According According According to the 

CAIB, the answer lies in the traits of the Shuttle Programʼs or- CAIB, the answer lies in the traits of the Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Programʼ Programʼ Programʼ Programʼ Programʼ Programʼ Programʼ Programʼ Programʼ Programʼ Programʼs organizational culture that “accepted escalating risk” and a “safety ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational culture culture culture culture culture culture culture culture culture culture culture culture that “accepted “accepted “accepted “accepted “accepted “accepted “accepted “accepted “accepted “accepted “accepted “accepted escalating escalating escalating escalating escalating escalating escalating escalating escalating escalating escalating escalating risk” and a “safety “safety “safety “safety “safety “safety “safety “safety “safety “safety “safety “safety 

program that was largely silent and ineffective.” Among them program program program program program program program program program program program that was largely silent and ineffective.” fective.” fective.” fective.” fective.” fective.” fective.” fective.” fective.” fective.” fective.” Among them 

were years of management decisions made under the duress were years of management management management management management management management management management management management management decisions decisions decisions decisions decisions decisions decisions decisions decisions decisions decisions decisions made under the duress 

of resource constraints, combined with shifting priorities and of resource resource resource resource resource resource resource resource resource resource resource constraints, constraints, constraints, constraints, constraints, constraints, constraints, constraints, constraints, constraints, constraints, combined combined combined combined combined combined combined combined combined combined combined with shifting shifting shifting shifting shifting shifting shifting shifting shifting shifting shifting priorities priorities priorities priorities priorities priorities priorities priorities priorities priorities priorities and 

schedule pressures. Another included the mischaracterization of schedule schedule schedule schedule schedule schedule schedule schedule schedule schedule schedule schedule pressures. pressures. pressures. pressures. pressures. pressures. pressures. pressures. pressures. pressures. pressures. pressures. Another Another Another Another Another Another Another Another Another Another Another Another included included included included included included included included included included included included the mischaracterization mischaracterization mischaracterization mischaracterization mischaracterization mischaracterization mischaracterization mischaracterization mischaracterization mischaracterization mischaracterization mischaracterization of 

the Shuttle as an operational rather than a developmental vehicle. the Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle as an operational operational operational operational operational operational operational operational operational operational operational rather than a developmental developmental developmental developmental developmental developmental developmental developmental developmental developmental developmental vehicle. vehicle. vehicle. vehicle. vehicle. vehicle. vehicle. vehicle. vehicle. vehicle. vehicle. 

Organizational safety practices emerged that were detrimental, Organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational safety practices practices practices practices practices practices practices practices practices practices practices emerged that were detrimental, detrimental, detrimental, detrimental, detrimental, detrimental, detrimental, detrimental, detrimental, detrimental, detrimental, 

including reliance on past success as a substitute for sound en- including including including including including including including including including including including reliance reliance reliance reliance reliance reliance reliance reliance reliance reliance reliance on past success success success success success success success success success success success as a substitute substitute substitute substitute substitute substitute substitute substitute substitute substitute substitute for sound engineering practices, ineffective communication of critical safety gineering gineering gineering gineering gineering gineering gineering gineering gineering gineering gineering practices, practices, practices, practices, practices, practices, practices, practices, practices, practices, practices, ineffective fective fective fective fective fective fective fective fective fective fective communication communication communication communication communication communication communication communication communication communication communication of critical critical critical critical critical critical critical critical critical critical critical safety 

information, and a decision-making process that operated out- information, information, information, information, information, information, information, information, information, information, information, information, and a decision-making decision-making decision-making decision-making decision-making decision-making decision-making decision-making decision-making decision-making decision-making decision-making process process process process process process process process process process process process that operated operated operated operated operated operated operated operated operated operated operated operated outside the organizationʼs rules. The CAIB recommendations and side the organizationʼ ganizationʼ ganizationʼ ganizationʼ ganizationʼ ganizationʼ ganizationʼ ganizationʼ ganizationʼ ganizationʼ ganizationʼs rules. The CAIB recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations and 

fi ndings in the risk management area and the Safety and Mission findings in the risk management management management management management management management management management management management management area and the Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission 

Success Week responses from the workforce provide a clear Success Success Success Success Success Success Success Success Success Success Success Week responses responses responses responses responses responses responses responses responses responses responses from the workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce workforce provide provide provide provide provide provide provide provide provide provide provide a clear 

picture of the issues and challenges NASA faces in managing picture picture picture picture picture picture picture picture picture picture picture picture of the issues and challenges challenges challenges challenges challenges challenges challenges challenges challenges challenges challenges challenges NASA faces in managing managing managing managing managing managing managing managing managing managing managing managing 

future risks.

9.2 CATEGORY ATEGORY R-O-F S R-O-F SUMMARY

Overall there were four recommendations, two observations, Overall Overall Overall Overall Overall Overall Overall Overall Overall Overall there were four recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, recommendations, two observations, observations, observations, observations, observations, observations, observations, observations, observations, observations, 

and 12 fi ndings that the Diaz Team determined had broad NASA and 12 findings that the Diaz Team determined determined determined determined determined determined determined determined determined determined determined had broad NASA

applicability to Risk Management. This is the largest number of applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability to Risk Management. Management. Management. Management. Management. Management. Management. Management. Management. Management. This is the largest number of 

R-O-Fs assigned to any one Diaz Team category. Table 23 shows R-O-Fs assigned assigned assigned assigned assigned assigned assigned assigned assigned assigned assigned to any one Diaz Team category category category category category category category category category category category. Table 23 shows 

these 18 R-O-Fs in brief summary statement form, along with these 18 R-O-Fs in brief summary summary summary summary summary summary summary summary summary summary statement statement statement statement statement statement statement statement statement statement form, along with 

brief discussion points on NASA applicability. Three themes brief discussion discussion discussion discussion discussion discussion discussion discussion discussion discussion discussion points on NASA applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability applicability. Three themes 

emerge from these discussion points as highlighted in the bullet emerge from these discussion discussion discussion discussion discussion discussion discussion discussion discussion discussion points as highlighted highlighted highlighted highlighted highlighted highlighted highlighted highlighted highlighted highlighted in the bullet 

points above.

9.3 DISCUSSION ISCUSSION

The fi rst risk management theme that stands out is the necessity The first risk management management management management management management management management management management theme that stands out is the necessity necessity necessity necessity necessity necessity necessity necessity necessity necessity 

to set uniform standards and assessment methodologies across to set uniform uniform uniform uniform uniform uniform uniform uniform uniform uniform uniform standards standards standards standards standards standards standards standards standards standards standards and assessment assessment assessment assessment assessment assessment assessment assessment assessment assessment assessment methodologies methodologies methodologies methodologies methodologies methodologies methodologies methodologies methodologies methodologies methodologies across 

all programs. The CAIB clearly saw discrepancies in safety all programs. programs. programs. programs. programs. programs. programs. programs. programs. programs. The CAIB clearly clearly clearly clearly clearly clearly clearly clearly clearly clearly saw discrepancies discrepancies discrepancies discrepancies discrepancies discrepancies discrepancies discrepancies discrepancies discrepancies in safety 

standards Agency-wide as evidenced by the different microme- standards standards standards standards standards standards standards standards standards standards Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide Agency-wide as evidenced evidenced evidenced evidenced evidenced evidenced evidenced evidenced evidenced evidenced by the different microme- microme- microme- microme- microme- microme- microme- microme- microme- micrometeoroid and orbital debris safety standards between the Shuttle teoroid teoroid teoroid teoroid teoroid teoroid teoroid teoroid teoroid teoroid and orbital orbital orbital orbital orbital orbital orbital orbital orbital orbital debris safety standards standards standards standards standards standards standards standards standards standards between between between between between between between between between between the Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle 

and ISS programs. Additionally, these standards were treated by and ISS programs. programs. programs. programs. programs. programs. programs. programs. programs. programs. Additionally Additionally Additionally Additionally Additionally Additionally Additionally Additionally Additionally Additionally, these standards standards standards standards standards standards standards standards standards standards were treated treated treated treated treated treated treated treated treated treated by 

managers as being guidelines rather than requirements. For the managers managers managers managers managers managers managers managers managers managers managers as being guidelines guidelines guidelines guidelines guidelines guidelines guidelines guidelines guidelines guidelines guidelines rather than requirements. requirements. requirements. requirements. requirements. requirements. requirements. requirements. requirements. requirements. requirements. For the 

Shuttle Program, the CAIB R-O-Fs also highlighted the lack of Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Program, Program, Program, Program, Program, Program, Program, Program, Program, Program, the CAIB R-O-Fs also highlighted highlighted highlighted highlighted highlighted highlighted highlighted highlighted highlighted highlighted the lack of 

risk assessment independence and integration; no one was taking risk assessment assessment assessment assessment assessment assessment assessment assessment assessment assessment assessment independence independence independence independence independence independence independence independence independence independence independence and integration; integration; integration; integration; integration; integration; integration; integration; integration; integration; integration; no one was taking 

a systematic view of risk. 

Another major theme embodied in the CAIB Report was man- Another Another Another Another Another Another Another Another Another Another major theme embodied embodied embodied embodied embodied embodied embodied embodied embodied embodied in the CAIB Report was managementʼs understanding of the risks associated with key deci- agementʼ agementʼ agementʼ agementʼ agementʼ agementʼ agementʼ agementʼ agementʼ agementʼs understanding understanding understanding understanding understanding understanding understanding understanding understanding understanding of the risks associated associated associated associated associated associated associated associated associated associated with key decisions. Systematically, resource constraints and schedule pres- sions. Systematically Systematically Systematically Systematically Systematically Systematically Systematically Systematically Systematically Systematically Systematically, resource resource resource resource resource resource resource resource resource resource resource constraints constraints constraints constraints constraints constraints constraints constraints constraints constraints constraints and schedule schedule schedule schedule schedule schedule schedule schedule schedule schedule schedule pressures clouded management decisions. Safety factors on hardware sures clouded clouded clouded clouded clouded clouded clouded clouded clouded clouded management management management management management management management management management management decisions. decisions. decisions. decisions. decisions. decisions. decisions. decisions. decisions. decisions. Safety factors factors factors factors factors factors factors factors factors factors on hardware hardware hardware hardware hardware hardware hardware hardware hardware hardware 

were not maintained. Adequate replacement spares did not exist were not maintained. maintained. maintained. maintained. maintained. maintained. maintained. maintained. maintained. maintained. maintained. Adequate Adequate Adequate Adequate Adequate Adequate Adequate Adequate Adequate Adequate Adequate replacement replacement replacement replacement replacement replacement replacement replacement replacement replacement replacement spares did not exist 

for key components. When combined with a safety offi ce that for key components. components. components. components. components. components. components. components. components. components. When combined combined combined combined combined combined combined combined combined combined with a safety office that 

was not independently resourced, the Shuttleʼs ability to manage was not independently independently independently independently independently independently independently independently independently independently independently resourced, resourced, resourced, resourced, resourced, resourced, resourced, resourced, resourced, resourced, resourced, the Shuttleʼ Shuttleʼ Shuttleʼ Shuttleʼ Shuttleʼ Shuttleʼ Shuttleʼ Shuttleʼ Shuttleʼ Shuttleʼ Shuttleʼs ability ability ability ability ability ability ability ability ability ability ability to manage 

risk and conduct safe operations was fundamentally imperiled. risk and conduct conduct conduct conduct conduct conduct conduct conduct conduct conduct safe operations operations operations operations operations operations operations operations operations operations was fundamentally fundamentally fundamentally fundamentally fundamentally fundamentally fundamentally fundamentally fundamentally fundamentally imperiled. imperiled. imperiled. imperiled. imperiled. imperiled. imperiled. imperiled. imperiled. imperiled. 

To address this issue, one of the CAIB recommendations spe- To address address address address address address address address address address address this issue, one of the CAIB recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations specifi cally called for NASA to “adopt and maintain a Shuttle fl ight cifically called for NASA to “adopt and maintain maintain maintain maintain maintain maintain maintain maintain maintain maintain a Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle Shuttle flight 

schedule that is consistent with available resources.” The Board schedule schedule schedule schedule schedule schedule schedule schedule schedule schedule that is consistent consistent consistent consistent consistent consistent consistent consistent consistent consistent with available available available available available available available available available available resources.” resources.” resources.” resources.” resources.” resources.” resources.” resources.” resources.” resources.” The Board 

clearly understood that deadlines are an important management clearly clearly clearly clearly clearly clearly clearly clearly clearly clearly clearly understood understood understood understood understood understood understood understood understood understood understood that deadlines deadlines deadlines deadlines deadlines deadlines deadlines deadlines deadlines deadlines deadlines are an important important important important important important important important important important important management management management management management management management management management management management 

tool; however, the message to NASA was that deadlines must tool; however however however however however however however however however however, the message message message message message message message message message message to NASA was that deadlines deadlines deadlines deadlines deadlines deadlines deadlines deadlines deadlines deadlines must 

be systematically evaluated from a risk standpoint to determine be systematically systematically systematically systematically systematically systematically systematically systematically systematically systematically systematically evaluated evaluated evaluated evaluated evaluated evaluated evaluated evaluated evaluated evaluated evaluated from a risk standpoint standpoint standpoint standpoint standpoint standpoint standpoint standpoint standpoint standpoint standpoint to determine determine determine determine determine determine determine determine determine determine determine 

acceptability of schedules. Safety and Mission Success Week acceptability acceptability acceptability acceptability acceptability acceptability acceptability acceptability acceptability acceptability of schedules. schedules. schedules. schedules. schedules. schedules. schedules. schedules. schedules. schedules. Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Success Success Success Success Success Success Success Success Success Success Week 

responses clearly agreed with this critical issue. One input noted responses responses responses responses responses responses responses responses responses responses responses clearly clearly clearly clearly clearly clearly clearly clearly clearly clearly clearly agreed with this critical critical critical critical critical critical critical critical critical critical critical issue. One input noted 

that independent assessments should be alert to the consequences that independent independent independent independent independent independent independent independent independent independent assessments assessments assessments assessments assessments assessments assessments assessments assessments assessments should be alert to the consequences consequences consequences consequences consequences consequences consequences consequences consequences consequences 

of schedule pressures on technical decisions affecting safety and of schedule schedule schedule schedule schedule schedule schedule schedule schedule schedule pressures pressures pressures pressures pressures pressures pressures pressures pressures pressures on technical technical technical technical technical technical technical technical technical technical decisions decisions decisions decisions decisions decisions decisions decisions decisions decisions affecting fecting fecting fecting fecting fecting fecting fecting fecting fecting safety and 

mission success, as well as program success in infrastructure or mission mission mission mission mission mission mission mission mission mission success, success, success, success, success, success, success, success, success, success, as well as program program program program program program program program program program success success success success success success success success success success in infrastructure infrastructure infrastructure infrastructure infrastructure infrastructure infrastructure infrastructure infrastructure infrastructure or 

nontechnical areas.

As for resources, the Board noted that adequate resources and As for resources, resources, resources, resources, resources, resources, resources, resources, resources, resources, the Board noted that adequate adequate adequate adequate adequate adequate adequate adequate adequate adequate resources resources resources resources resources resources resources resources resources resources and 

independent assessments are critical to risk management and independent independent independent independent independent independent independent independent independent independent independent assessments assessments assessments assessments assessments assessments assessments assessments assessments assessments assessments are critical critical critical critical critical critical critical critical critical critical critical to risk management management management management management management management management management management management and 

decision-making. Agency-wide, NASA can look at its programs decision-making. decision-making. decision-making. decision-making. decision-making. decision-making. decision-making. decision-making. decision-making. decision-making. Agency-wide, Agency-wide, Agency-wide, Agency-wide, Agency-wide, Agency-wide, Agency-wide, Agency-wide, Agency-wide, Agency-wide, NASA can look at its programs programs programs programs programs programs programs programs programs programs 

to determine whether independent organizations are properly re- to determine determine determine determine determine determine determine determine determine determine determine whether whether whether whether whether whether whether whether whether whether whether independent independent independent independent independent independent independent independent independent independent independent organizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations are properly properly properly properly properly properly properly properly properly properly properly resourced and suffi ciently independent. Acquisition approaches for sourced sourced sourced sourced sourced sourced sourced sourced sourced sourced and sufficiently ciently ciently ciently ciently ciently ciently ciently ciently ciently independent. independent. independent. independent. independent. independent. independent. independent. independent. independent. Acquisition Acquisition Acquisition Acquisition Acquisition Acquisition Acquisition Acquisition Acquisition Acquisition approaches approaches approaches approaches approaches approaches approaches approaches approaches approaches for 

spares and contractor support also require understanding of risks. spares and contractor contractor contractor contractor contractor contractor contractor contractor contractor contractor support support support support support support support support support support also require require require require require require require require require require understanding understanding understanding understanding understanding understanding understanding understanding understanding understanding of risks. 

A Safety and Mission Success Week response clearly articulated A Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Success Success Success Success Success Success Success Success Success Success Success Week response response response response response response response response response response response clearly clearly clearly clearly clearly clearly clearly clearly clearly clearly clearly articulated articulated articulated articulated articulated articulated articulated articulated articulated articulated articulated 

this issue by stating that risk-based acquisition management this issue by stating stating stating stating stating stating stating stating stating stating that risk-based risk-based risk-based risk-based risk-based risk-based risk-based risk-based risk-based risk-based acquisition acquisition acquisition acquisition acquisition acquisition acquisition acquisition acquisition acquisition management management management management management management management management management management 

CAIB Report Chapter 1, p25:

As the investigation continued, it revealed a NASA culture that had gradually begun to accept escalating risk, 

and a NASA safety program that was largely silent and ineffective.
4 7
4 8

must be re-emphasized as a fundamental tool for ensuring that must be re-emphasized re-emphasized re-emphasized re-emphasized re-emphasized re-emphasized re-emphasized re-emphasized re-emphasized re-emphasized re-emphasized as a fundamental fundamental fundamental fundamental fundamental fundamental fundamental fundamental fundamental fundamental fundamental tool for ensuring ensuring ensuring ensuring ensuring ensuring ensuring ensuring ensuring ensuring ensuring that 

acquisition approaches enhance the likelihood of mission and acquisition acquisition acquisition acquisition acquisition acquisition acquisition acquisition acquisition acquisition acquisition approaches approaches approaches approaches approaches approaches approaches approaches approaches approaches approaches enhance enhance enhance enhance enhance enhance enhance enhance enhance enhance enhance the likelihood likelihood likelihood likelihood likelihood likelihood likelihood likelihood likelihood likelihood likelihood of mission mission mission mission mission mission mission mission mission mission mission and 

safety success.

The third major theme of Risk Management within the CAIB The third major theme of Risk Management within the CAIB

fi ndings applies to the incremental and insidious growth of risk findings applies to the incremental and insidious growth of risk

in programs. As described above, the lack of uniformity in risk in programs. As described above, the lack of uniformity in risk

assessment standards, combined with decisions under schedule assessment standards, combined with decisions under schedule

and resource constraints, led to added overall risk. As stated in and resource constraints, led to added overall risk. As stated in

the CAIB Report, “These little pieces of risk add up until manag- the CAIB Report, “These little pieces of risk add up until managers are no longer aware of the total program risk, and are, in fact, ers are no longer aware of the total program risk, and are, in fact,

gambling.” The fi ndings of the CAIB provide lessons that NASA gambling.” The findings of the CAIB provide lessons that NASA

can utilize across its programs to improve its risk management can utilize across its programs to improve its risk management

practices. practices.

One fi nding suggests NASA look outside its own organization, One finding suggests suggests suggests suggests suggests suggests suggests suggests suggests suggests suggests suggests NASA look outside outside outside outside outside outside outside outside outside outside outside outside its own organization, ganization, ganization, ganization, ganization, ganization, ganization, ganization, ganization, ganization, ganization, ganization, 

such as the Air Force, for valuable risk management lessons such as the Air Force, for valuable valuable valuable valuable valuable valuable valuable valuable valuable valuable valuable risk management management management management management management management management management management management lessons lessons lessons lessons lessons lessons lessons lessons lessons lessons lessons 

that can be applied to its programs. Others suggest logical and that can be applied applied applied applied applied applied applied applied applied applied applied to its programs. programs. programs. programs. programs. programs. programs. programs. programs. programs. programs. Others suggest suggest suggest suggest suggest suggest suggest suggest suggest suggest suggest logical logical logical logical logical logical logical logical logical logical logical and 

systematic risk assessment methodologies be used across the systematic systematic systematic systematic systematic systematic systematic systematic systematic systematic systematic systematic risk assessment assessment assessment assessment assessment assessment assessment assessment assessment assessment assessment assessment methodologies methodologies methodologies methodologies methodologies methodologies methodologies methodologies methodologies methodologies methodologies methodologies be used across the 

Agency. Finally, proper organizational structure is necessary for Agency. Finally Finally Finally Finally Finally Finally Finally Finally Finally Finally Finally, proper organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational structure structure structure structure structure structure structure structure structure structure structure is necessary necessary necessary necessary necessary necessary necessary necessary necessary necessary necessary for 

placing a premium on safety and reliability. This includes safety placing placing placing placing placing placing placing placing placing placing placing placing a premium premium premium premium premium premium premium premium premium premium premium premium on safety and reliability reliability reliability reliability reliability reliability reliability reliability reliability reliability reliability reliability. This includes includes includes includes includes includes includes includes includes includes includes includes safety 

and engineering organizations owning the process of determin- and engineering engineering engineering engineering engineering engineering engineering engineering engineering engineering engineering organizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations ganizations owning the process process process process process process process process process process process of determin- determin- determin- determin- determin- determin- determin- determin- determin- determin- determining, maintaining, and waiving technical requirements. 

The CAIB defi ned the set of circumstances and traits that led The CAIB defined the set of circumstances circumstances circumstances circumstances circumstances circumstances circumstances circumstances circumstances circumstances circumstances and traits that led 

to a NASA organizational culture of accepting increasing risk to a NASA organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational culture culture culture culture culture culture culture culture culture culture culture of accepting accepting accepting accepting accepting accepting accepting accepting accepting accepting accepting increasing increasing increasing increasing increasing increasing increasing increasing increasing increasing increasing risk 

as “Normalization of Deviance.” This is a term used as a social as “Normalization “Normalization “Normalization “Normalization “Normalization “Normalization “Normalization “Normalization “Normalization “Normalization “Normalization of Deviance.” Deviance.” Deviance.” Deviance.” Deviance.” Deviance.” Deviance.” Deviance.” Deviance.” Deviance.” Deviance.” This is a term used as a social 

construct by the author of construct by the author of The Challenger Launch Decision Launch Decision, Dr. 

Diane Vaughan, a Boston College Professor. The NASA work- Diane Vaughan, aughan, aughan, aughan, aughan, aughan, aughan, aughan, aughan, aughan, aughan, a Boston College College College College College College College College College College College Professor Professor Professor Professor Professor Professor Professor Professor Professor Professor Professor. The NASA workforce expounded on this cultural theme during Safety and Mis- force expounded expounded expounded expounded expounded expounded expounded expounded expounded expounded expounded expounded on this cultural cultural cultural cultural cultural cultural cultural cultural cultural cultural cultural cultural theme during Safety and Mission Success Week with inputs agreeing that there were clearly sion Success Success Success Success Success Success Success Success Success Success Success Week with inputs agreeing agreeing agreeing agreeing agreeing agreeing agreeing agreeing agreeing agreeing agreeing that there were clearly clearly clearly clearly clearly clearly clearly clearly clearly clearly clearly 

other examples within their experience of “Normalization of other examples examples examples examples examples examples examples examples examples examples examples examples within their experience experience experience experience experience experience experience experience experience experience experience experience of “Normalization “Normalization “Normalization “Normalization “Normalization “Normalization “Normalization “Normalization “Normalization “Normalization “Normalization “Normalization of 

Deviance.” The feedback suggested this stems from projects ac- Deviance.” Deviance.” Deviance.” Deviance.” Deviance.” Deviance.” Deviance.” Deviance.” Deviance.” Deviance.” Deviance.” The feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback suggested suggested suggested suggested suggested suggested suggested suggested suggested suggested suggested this stems from projects projects projects projects projects projects projects projects projects projects projects accepting greater levels of mission risk, including delivering sys- cepting cepting cepting cepting cepting cepting cepting cepting cepting cepting cepting greater greater greater greater greater greater greater greater greater greater greater levels of mission mission mission mission mission mission mission mission mission mission mission risk, including including including including including including including including including including including delivering delivering delivering delivering delivering delivering delivering delivering delivering delivering delivering systems that do not meet their original performance goals. Under the tems that do not meet their original original original original original original original original original original performance performance performance performance performance performance performance performance performance performance goals. Under the 

pressure of circumstances, some individuals may accept “good pressure pressure pressure pressure pressure pressure pressure pressure pressure pressure of circumstances, circumstances, circumstances, circumstances, circumstances, circumstances, circumstances, circumstances, circumstances, circumstances, some individuals individuals individuals individuals individuals individuals individuals individuals individuals individuals may accept “good 

enough” instead of specifi ed performance. Comprehensive ac- enough” enough” enough” enough” enough” enough” enough” enough” enough” enough” enough” instead instead instead instead instead instead instead instead instead instead instead of specifi specied performance. performance. performance. performance. performance. performance. performance. performance. performance. performance. performance. Comprehensive Comprehensive Comprehensive Comprehensive Comprehensive Comprehensive Comprehensive Comprehensive Comprehensive Comprehensive Comprehensive actions across NASA in managing risks will assure a high level of tions across NASA in managing managing managing managing managing managing managing managing managing managing risks will assure a high level of 

safety and mission success.

Agency-wide, a consistent set of risk assessment tools, applied Agency-wide, a consistent set of risk assessment tools, applied

in a uniform way, will help assure mission success. The CAIB in a uniform way, will help assure mission success. The CAIB

recommendation to provide the National Imagery and Mapping recommendation to provide the National Imagery and Mapping

Agency (NIMA) – now known as the National Geospatial-Intel- Agency (NIMA) – now known as the National Geospatial-Intelligence Agency (NGA) – imaging of the Orbiter as a standard ligence Agency (NGA) – imaging of the Orbiter as a standard

operating procedure, has its roots in managing the risk of each operating procedure, has its roots in managing the risk of each

Shuttle mission with the best data and information available. Shuttle mission with the best data and information available.

When applied throughout NASA, all programs would be served When applied throughout NASA, all programs would be served

by having the best information available by which to make deci- by having the best information available by which to make decisions that could impact safety and mission success. sions that could impact safety and mission success.

The feedback from Safety and Mission Success Week reinforced The feedback feedback feedback feedback feedback feedback feedback feedback feedback feedback from Safety and Mission Mission Mission Mission Mission Mission Mission Mission Mission Mission Success Success Success Success Success Success Success Success Success Success Week reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced reinforced 

the Diaz Team assessment: the Diaz Team assessment:

» Missions and programs are being driven by budget 

and schedule and a ʻfaster, better, cheaperʼ philosophy. and schedule and a ʻfaster and schedule and a ʻfaster and schedule and a ʻfaster and schedule and a ʻfaster and schedule and a ʻfaster and schedule and a ʻfaster and schedule and a ʻfaster and schedule and a ʻfaster and schedule and a ʻfaster, better , better , better , better , better , better , better , better , better, cheaper , cheaper , cheaper , cheaper , cheaper , cheaper , cheaper , cheaper , cheaperʼ philosophy philosophy philosophy philosophy philosophy philosophy philosophy philosophy philosophy. 

Cost and schedule pressures have surpassed technical 

quality as the drivers for decision making for projects.

» As in the CAIB Report, Center employees expressed 

concern over our “can do” attitude, which “goes too 

far and becomes arrogance, leaving us blind to external 

information.” It tempts us to accept greater risk than 

may be reasonable or responsible.

In addition to the actions in the Diaz Team Matrix that address In addition addition addition addition addition addition addition addition addition addition to the actions actions actions actions actions actions actions actions actions actions in the Diaz Team Matrix that address address address address address address address address address address 

each R-O-F, the Diaz Team has one goal addressing the Risk each R-O-F, the Diaz Team has one goal addressing addressing addressing addressing addressing addressing addressing addressing addressing addressing addressing the Risk 

Management category, as shown in Table 22. Management category, as shown in Table 22.

Table 22. The Diaz Team developed one goal for Risk Management.

Risk Management – Diaz Team Goal

The Agency should identify a set of risk management processes and tools which can be applied across all programs which 

recognize the diversity with respect to risk tolerance.
4 9

Table 23. The Diaz Team determined that four Recommendations, two Observations, and 12 Findings could be included in the Risk 

Management Category resulting in 11 actions.

Diaz 

Team # CAIB # CAIB Report Recommendations and Pertinent Factors Diaz Team Discussion Action # Responsible

R12 R3.8-1 Obtain suffi cient spare Reinforced Carbon-Carbon 

panels

Assure adequacy of hardware for safe decisionmaking 3 AE

R17 R4.2-4 Shuttle to be operated with same micrometeroid 

safety as ISS

Need same risk standards and assessment 

methodologies 5 Q

R19 R6.2-1 Adopt fl ight schedule consistent with available 

resources

Schedule with underlying rationale and risk 

assessment 6 AE

R21 R6.3-2 Establish MOU with NIMA for imaging orbiter The need to use national assets to assess 

spacecraft health applies to many programs. 8 G

O1 O10.1-1 Develop public risk acceptance policy for launch 

and re-entry

NASA should continue to develop public risk 

policies 11 Q

O25 O10.10-1 Reinstate safety factor of 1.4 for attach rings All programs need consistent design factors to 

manage risk 16 AE

F12 F3.3-3 Only periodic visual and touch tests on accepted 

RCC

Appropriate in-service inspection for high-risk 

areas 20 AE

F35 F3.8-5 Inadequate number of spare RCC panels in 

program

Programs need robust supply chains with detailed 

logistics 22 AE

F53 F4.2-16 Shuttle and ISS had different margin criteria for 

MMOD

Risk determination needs uniform application 

across Agency 5 Q

F65 F6.1-10 Failure to perform adequate trend analysis on 

foam losses

Anomalies must be captured and evaluated for 

risk mitigation 29 AE

F108 F7.4-3 No progress in integrated and independent Shuttle 

risk

Uniform risk assessment standards across 

programs needed 36 Q

F110 F7.4-5 No risk information from a systematic view across 

Shuttle

Uniform risk assessment standards across 

programs needed 36 Q

F119 F10.1-1 Columbia breakup had potential to cause public 

casualties

NASA should continue to develop public risk 

policies 11 Q

F120 F10.1-2 Lack of public casualties from Columbia expected 

outcome

Programs need to factor in public risk analysis in 

planning 11 Q

F121 F10.1-3 US space fl ights have fl awless public safety 

record

Logical risk assessments for safety should be 

used 11 Q

F122 F10.1-4 Launch range public safety standards less than 

one in million NASA recognizes safety requirements 11 Q

F123 F10.1-5 Public safety standards not followed for Orbiter 

re-entry NASA recognizes safety requirements 11 Q

F127 F10.4-1 Shuttle industrial safety programs are in good 

health

Continuous review of health of industrial safety 

program needed 40 Q
5 0

10.1 SUMMARY

In summary, the CAIB Report includes signifi cant technical and In summary summary summary summary summary summary summary summary summary summary summary summary, the CAIB Report includes includes includes includes includes includes includes includes includes includes includes includes signifi signicant technical technical technical technical technical technical technical technical technical technical technical technical and 

non-technical R-O-Fs, which NASA leaders must adhere to in non-technical non-technical non-technical non-technical non-technical non-technical non-technical non-technical non-technical non-technical non-technical R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, which NASA leaders leaders leaders leaders leaders leaders leaders leaders leaders leaders leaders must adhere to in 

order to help the Agency move forward to meet the challenges order to help the Agency move forward forward forward forward forward forward forward forward forward forward forward forward to meet the challenges challenges challenges challenges challenges challenges challenges challenges challenges challenges challenges challenges 

of the future. The Diaz Team realizes that, in some respects, the of the future. future. future. future. future. future. future. future. future. future. future. The Diaz Team realizes realizes realizes realizes realizes realizes realizes realizes realizes realizes realizes that, in some respects, respects, respects, respects, respects, respects, respects, respects, respects, respects, respects, the 

most challenging changes will be those which pertain to culture, most challenging challenging challenging challenging challenging challenging challenging challenging challenging challenging challenging challenging changes changes changes changes changes changes changes changes changes changes changes changes will be those which pertain pertain pertain pertain pertain pertain pertain pertain pertain pertain pertain pertain to culture, culture, culture, culture, culture, culture, culture, culture, culture, culture, culture, culture, 

or those which are the non-technical R-O-Fs noted in the CAIB or those which are the non-technical non-technical non-technical non-technical non-technical non-technical non-technical non-technical non-technical non-technical non-technical R-O-Fs noted in the CAIB 

Report. 

The Team knows that the organizational changes recommended The Team knows that the organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational changes changes changes changes changes changes changes changes changes changes changes recommended recommended recommended recommended recommended recommended recommended recommended recommended recommended recommended 

in the CAIB Report will require sustained planning and imple- in the CAIB Report will require require require require require require require require require require require require sustained sustained sustained sustained sustained sustained sustained sustained sustained sustained sustained sustained planning planning planning planning planning planning planning planning planning planning planning planning and implementation over time to achieve the desired future the CAIB and mentation mentation mentation mentation mentation mentation mentation mentation mentation mentation mentation over time to achieve achieve achieve achieve achieve achieve achieve achieve achieve achieve achieve the desired desired desired desired desired desired desired desired desired desired desired future the CAIB and 

NASA foresee. When making cultural change, large organiza- NASA foresee. foresee. foresee. foresee. foresee. foresee. foresee. foresee. foresee. foresee. foresee. foresee. When making cultural cultural cultural cultural cultural cultural cultural cultural cultural cultural cultural cultural change, change, change, change, change, change, change, change, change, change, change, change, large organiza- ganiza- ganiza- ganiza- ganiza- ganiza- ganiza- ganiza- ganiza- ganiza- ganiza- ganizations such as NASA need to assure that, throughout the change tions such as NASA need to assure that, throughout throughout throughout throughout throughout throughout throughout throughout throughout throughout throughout the change 

process, the organizationʼs core values are both relied on and process, process, process, process, process, process, process, process, process, process, process, the organizationʼ ganizationʼ ganizationʼ ganizationʼ ganizationʼ ganizationʼ ganizationʼ ganizationʼ ganizationʼ ganizationʼ ganizationʼs core values are both relied on and 

sustained. The Team believes these core values will help the sustained. sustained. sustained. sustained. sustained. sustained. sustained. sustained. sustained. sustained. sustained. The Team believes believes believes believes believes believes believes believes believes believes believes these core values will help the 

Agencyʼs leaders take on the serious challenges ahead, which Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼs leaders leaders leaders leaders leaders leaders leaders leaders leaders leaders leaders take on the serious serious serious serious serious serious serious serious serious serious serious challenges challenges challenges challenges challenges challenges challenges challenges challenges challenges challenges ahead, which 

should yield improved safety, performance excellence, and mis- should yield improved improved improved improved improved improved improved improved improved improved improved improved safety, performance performance performance performance performance performance performance performance performance performance performance performance excellence, excellence, excellence, excellence, excellence, excellence, excellence, excellence, excellence, excellence, excellence, excellence, and mission success. 

The proposed actions in the Diaz Team Report are based on cul- The proposed proposed proposed proposed proposed proposed proposed proposed proposed proposed proposed actions actions actions actions actions actions actions actions actions actions actions in the Diaz Team Report are based on culture-related issues identifi ed by NASA leadership and the work- ture-related ture-related ture-related ture-related ture-related ture-related ture-related ture-related ture-related ture-related ture-related ture-related issues identifi identifi identifi identifi identifi identifi identifi identifi identifi identifi identifi identified by NASA leadership leadership leadership leadership leadership leadership leadership leadership leadership leadership leadership leadership and the workforce in the areas of: leadership, learning, communication, pro- force in the areas of: leadership, leadership, leadership, leadership, leadership, leadership, leadership, leadership, leadership, leadership, leadership, learning, learning, learning, learning, learning, learning, learning, learning, learning, learning, learning, communication, communication, communication, communication, communication, communication, communication, communication, communication, communication, communication, processes and rules, technical capabilities, organizational structure, cesses and rules, technical technical technical technical technical technical technical technical technical technical technical capabilities, capabilities, capabilities, capabilities, capabilities, capabilities, capabilities, capabilities, capabilities, capabilities, capabilities, organizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational ganizational structure, structure, structure, structure, structure, structure, structure, structure, structure, structure, structure, 

and risk management. The Team believes this systemic approach and risk management. management. management. management. management. management. management. management. management. management. management. management. The Team believes believes believes believes believes believes believes believes believes believes believes believes this systemic systemic systemic systemic systemic systemic systemic systemic systemic systemic systemic systemic approach approach approach approach approach approach approach approach approach approach approach approach 

to cultural change at this critical juncture of the Agencyʼs history to cultural cultural cultural cultural cultural cultural cultural cultural cultural cultural cultural change at this critical critical critical critical critical critical critical critical critical critical critical juncture juncture juncture juncture juncture juncture juncture juncture juncture juncture juncture of the Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼ Agencyʼs history history history history history history history history history history history 

will yield a NASA culture that is signifi cantly more responsive will yield a NASA culture culture culture culture culture culture culture culture culture culture culture culture that is signifi signicantly more responsive responsive responsive responsive responsive responsive responsive responsive responsive responsive responsive responsive 

and prepared for the promising opportunities of the American and prepared prepared prepared prepared prepared prepared prepared prepared prepared prepared prepared for the promising promising promising promising promising promising promising promising promising promising promising opportunities opportunities opportunities opportunities opportunities opportunities opportunities opportunities opportunities opportunities opportunities of the American American American American American American American American American American American 

space programʼs future. space programʼs future.

The seven Diaz Team goals are shown in Table 24. In order to The seven Diaz Team goals are shown in Table 24. In order to 

gain a more thorough understanding of the Diaz Teamʼs determi- gain a more thorough thorough thorough thorough thorough thorough thorough thorough thorough thorough thorough understanding understanding understanding understanding understanding understanding understanding understanding understanding understanding understanding of the Diaz Teamʼs determi- determi- determi- determi- determi- determi- determi- determi- determi- determi- determinations, detailed examination of the entire Diaz Team Matrix and nations, nations, nations, nations, nations, nations, nations, nations, nations, nations, nations, detailed detailed detailed detailed detailed detailed detailed detailed detailed detailed detailed examination examination examination examination examination examination examination examination examination examination examination of the entire Diaz Team Matrix and 

its 40 actions (Appendix A) and the tables in each of the forego- its 40 actions actions actions actions actions actions actions actions actions actions actions actions (Appendix (Appendix (Appendix (Appendix (Appendix (Appendix (Appendix (Appendix (Appendix (Appendix (Appendix (Appendix A) and the tables in each of the forego- forego- forego- forego- forego- forego- forego- forego- forego- forego- forego- foregoing chapters is critical.

NASA indeed stands at a crossroads. One path is a continuation NASA indeed stands at a crossroads. crossroads. crossroads. crossroads. crossroads. crossroads. crossroads. crossroads. crossroads. crossroads. crossroads. One path is a continuation continuation continuation continuation continuation continuation continuation continuation continuation continuation continuation 

of the course that allowed the of the course that allowed allowed allowed allowed allowed allowed the Challenger Challenger and Columbia accidents to occur. The new path of change may be diffi cult, particu- dents to occur. The new path of change may be difficult, particu- particu- particu- particu- particu- particu- particu- particu- particu- particu- particularly at the start, and sometimes the goal is not always in sight. larly at the start, and sometimes sometimes sometimes sometimes sometimes sometimes sometimes sometimes sometimes sometimes sometimes the goal is not always in sight. 

But the rewards for walking this path are far greater than those But the rewards rewards rewards rewards rewards rewards rewards rewards rewards rewards rewards for walking walking walking walking walking walking walking walking walking walking walking this path are far greater greater greater greater greater greater greater greater greater greater greater than those 

the old path could ever offer us. the old path could ever offer us. 

For NASA to embark on the new pathway, some fundamental For NASA to embark on the new pathway pathway pathway pathway pathway pathway pathway pathway pathway pathway pathway, some fundamental fundamental fundamental fundamental fundamental fundamental fundamental fundamental fundamental fundamental fundamental 

reforms must be instituted. These are encompassed by the 40 reforms reforms reforms reforms reforms reforms reforms reforms reforms reforms reforms reforms must be instituted. instituted. instituted. instituted. instituted. instituted. instituted. instituted. instituted. instituted. instituted. instituted. These are encompassed encompassed encompassed encompassed encompassed encompassed encompassed encompassed encompassed encompassed encompassed encompassed by the 40 

Diaz Team actions and seven goals identifi ed in the Report. The Diaz Team actions actions actions actions actions actions actions actions actions actions actions and seven goals identifi identifi identifi identifi identifi identifi identifi identifi identifi identifi identified in the Report. Report. Report. Report. Report. Report. Report. Report. Report. Report. Report. The 

essence of these can be captured in three overarching reforms:

• NASA must assure that appropriate checks and bal- NASA must assure that appropriate checks and balances are in place to develop and operate its missions 

safely, and must undertake the organizational changes safely, and must undertake the organizational changes 

necessary to make this happen. The organizational necessary to make this happen. The organizational 

structure should help clarify roles and responsibilities 

of individual employees, work groups and leadership. 

Every member of the workforce must know his or her 

position in the organization and all must know their position in the organization and all must know their 

authority, responsibility and accountability for assur- authority, responsibility and accountability for assuring mission success. The entire workforce must also be ing mission success. The entire workforce must also be 

aware of and understand the rules.

• NASA must enhance communications at all levels NASA must enhance communications at all levels 

with a focus on fostering diversity of viewpoints and 

eliminating fear of retribution. A communications cul- eliminating fear of retribution. A communications culture must be established with formal communications 

procedures to ensure effective communications fl ow up procedures to ensure effective communications flow up 

and down the chain of command and across organiza- and down the chain of command and across organizational lines. Communications channels should be suffi ciently fl exible to support, encourage, and objectively ficiently flexible to support, encourage, and objectively 

evaluate all viewpoints, ensuring sound decision-making practices.

• NASA must focus on the ways it is managing risk. NASA must focus on the ways it is managing risk. 

Safety, mission success and program performance Safety, mission success and program performance 

must not be the product of schedule and budget pressures alone. Technological and workforce factors must sures alone. Technological and workforce factors must 

be considered in program planning and decision-making as well. A critical role of leadership is to ensure ing as well. A critical role of leadership is to ensure 

there is an appropriate balance between requirements, 

resources and risk. NASA must assure that the work- resources and risk. NASA must assure that the workforce has the appropriate processes, tools and technical 

capabilities to accomplish this.

10.2 NEXT STEPS

It should be noted the NASA Administrator asked the Team in It should be noted the NASA Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator asked the Team in 

its charter to identify broadly applicable R-O-Fs in the CAIB its charter charter charter charter charter charter charter charter charter charter to identify identify identify identify identify identify identify identify identify identify broadly broadly broadly broadly broadly broadly broadly broadly broadly broadly applicable applicable applicable applicable applicable applicable applicable applicable applicable applicable R-O-Fs in the CAIB 

Report, recommend actions to address those R-O-Fs, and submit Report, Report, Report, Report, Report, Report, Report, Report, Report, Report, recommend recommend recommend recommend recommend recommend recommend recommend recommend recommend actions actions actions actions actions actions actions actions actions actions to address address address address address address address address address address those R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, R-O-Fs, and submit 

a Report documenting its conclusions and recommendations to a Report documenting documenting documenting documenting documenting documenting documenting documenting documenting documenting documenting its conclusions conclusions conclusions conclusions conclusions conclusions conclusions conclusions conclusions conclusions conclusions and recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations recommendations to 

the NASA Deputy Administrator. The responsibility for prepar- the NASA Deputy Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator. The responsibility responsibility responsibility responsibility responsibility responsibility responsibility responsibility responsibility responsibility for preparing implementation plans to accomplish the 40 “specifi c actions” ing implementation implementation implementation implementation implementation implementation implementation implementation implementation implementation implementation plans to accomplish accomplish accomplish accomplish accomplish accomplish accomplish accomplish accomplish accomplish accomplish the 40 “specifi “specifi “specifi “specifi “specifi “specifi “specifi “specifi “specifi “specifi “specific actions” actions” actions” actions” actions” actions” actions” actions” actions” actions” actions” 

in the Diaz Team Matrix was given to the appropriate NASA in the Diaz Team Matrix was given to the appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate NASA

Headquarters organizations. The responsibility for accomplish- Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters Headquarters organizations. ganizations. ganizations. ganizations. ganizations. ganizations. ganizations. ganizations. ganizations. ganizations. ganizations. The responsibility responsibility responsibility responsibility responsibility responsibility responsibility responsibility responsibility responsibility responsibility for accomplish- accomplish- accomplish- accomplish- accomplish- accomplish- accomplish- accomplish- accomplish- accomplish- accomplishing the seven “Diaz Team Goals” is not identifi ed in this Report. ing the seven “Diaz Team Goals” is not identifi identifi identifi identifi identifi identifi identifi identifi identifi identified in this Report. Report. Report. Report. Report. Report. Report. Report. Report. Report. 

However, it is anticipated that the NASA Deputy Administrator However However However However However However However However However However, it is anticipated anticipated anticipated anticipated anticipated anticipated anticipated anticipated anticipated anticipated that the NASA Deputy Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator Administrator 

will provide direction to the development of all implementation will provide provide provide provide provide provide provide provide provide provide direction direction direction direction direction direction direction direction direction direction to the development development development development development development development development development development of all implementation implementation implementation implementation implementation implementation implementation implementation implementation implementation 

plans. It is recommended that all the implementation plans pre- plans. It is recommended recommended recommended recommended recommended recommended recommended recommended recommended recommended that all the implementation implementation implementation implementation implementation implementation implementation implementation implementation implementation plans prepared in response to the CAIB Report (i.e. RTF, CTF, Next Gen- pared in response response response response response response response response response response response to the CAIB Report (i.e. RTF, CTF, Next Generation Vehicle, Diaz Team and Aircraft Operations) be placed eration eration eration eration eration eration eration eration eration eration Vehicle, ehicle, ehicle, ehicle, ehicle, ehicle, ehicle, ehicle, ehicle, ehicle, Diaz Team and Aircraft Aircraft Aircraft Aircraft Aircraft Aircraft Aircraft Aircraft Aircraft Aircraft Operations) Operations) Operations) Operations) Operations) Operations) Operations) Operations) Operations) Operations) be placed 

under confi guration control, and any intent to establish other under configuration guration guration guration guration guration guration guration guration guration guration control, control, control, control, control, control, control, control, control, control, control, and any intent to establish establish establish establish establish establish establish establish establish establish establish other 

implementation plans be subject to approval by the Deputy Ad- implementation implementation implementation implementation implementation implementation implementation implementation implementation implementation plans be subject subject subject subject subject subject subject subject subject subject to approval approval approval approval approval approval approval approval approval approval by the Deputy Administrator. It is further anticipated that NASA will implement ministrator ministrator ministrator ministrator ministrator ministrator ministrator ministrator ministrator ministrator ministrator. It is further further further further further further further further further further further anticipated anticipated anticipated anticipated anticipated anticipated anticipated anticipated anticipated anticipated anticipated that NASA will implement implement implement implement implement implement implement implement implement implement implement 

the appropriate systems to coordinate and track the progress of the appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate appropriate systems systems systems systems systems systems systems systems systems systems to coordinate coordinate coordinate coordinate coordinate coordinate coordinate coordinate coordinate coordinate and track the progress progress progress progress progress progress progress progress progress progress of 

their implementation.

The Diaz Team suggests that NASA should periodically review The Diaz Team suggests suggests suggests suggests suggests suggests suggests suggests suggests suggests that NASA should periodically periodically periodically periodically periodically periodically periodically periodically periodically periodically review 

10.0 SUMMARY AND NEXT STEPS

CAIB Report Chapter 5, p9:

Organizational culture refers to the basic values, norms, beliefs, and practices that characterize the functioning of a particular institution. At the most basic level, organizational culture defi nes the assumptions 

that employees make as they carry out their work; it defi nes “the way we do things here.” An organization’s 

culture is a powerful force that persists through reorganizations and the departure of key personnel.
5 1

Table 24. Diaz Team Goals 

Leadership

The Agency should assess whether program management and budget formulation processes are adequate 

to assure there is an appropriate balance of requirements, resources, and risk to ensure safety and mission 

success.

Learning The Agency should identify an appropriate approach for the future development of a knowledge management 

system and infrastructure to assure knowledge retention and lessons learned.

Communication The Agency should continue the dialog that it began with the NASA workforce during Safety and Mission 

Success Week.

Processes 

and Rules The Agency should conduct a review of its approach to maintaining and managing rules.

Technical 

Capabilities 

The Agency should develop guidelines and metrics for assessing and maintaining its core competencies, 

including those associated with in-house work.

Organizational 

Structure The Agency should complete its current NASA-wide assessment and establish independent technical authority.

Risk 

Management

The Agency should identify a set of risk management processes and tools which can be applied across all 

programs which recognize the diversity with respect to risk tolerance.

and measure the progress of all implementation activities in and measure measure measure measure measure measure measure measure measure measure measure the progress progress progress progress progress progress progress progress progress progress progress of all implementation implementation implementation implementation implementation implementation implementation implementation implementation implementation implementation activities activities activities activities activities activities activities activities activities activities activities in 

response to the CAIB Report. It is suggested that this assess- response response response response response response response response response response response to the CAIB Report. Report. Report. Report. Report. Report. Report. Report. Report. Report. Report. It is suggested suggested suggested suggested suggested suggested suggested suggested suggested suggested suggested that this assess- assess- assess- assess- assess- assess- assess- assess- assess- assess- assessment be conducted six months after the release of the Diaz Team ment be conducted conducted conducted conducted conducted conducted conducted conducted conducted conducted conducted conducted six months after the release release release release release release release release release release release release of the Diaz Team 

Report, and annually thereafter. The Diaz Team, or some subset Report, Report, Report, Report, Report, Report, Report, Report, Report, Report, Report, and annually annually annually annually annually annually annually annually annually annually annually thereafter thereafter thereafter thereafter thereafter thereafter thereafter thereafter thereafter thereafter thereafter. The Diaz Team, or some subset 

thereof, could perform this assessment. 
APPENDIX A THE DIAZ TEAM MATRIX

1. The CAIB Report listed 29 recommendations, 27 

observations, and 137 fi ndings for a total of 193. From observations, and 137 findings for a total of 193. From 

the 193 R-O-Fs, the Diaz Team selected 85 that they the 193 R-O-Fs, the Diaz Team selected 85 that they 

believe are broadly applicable across all of NASA. 

2. The 85 broadly applicable R-O-Fs resulted in 40 

specifi c actions. Each action is comprised of multiple specific actions. Each action is comprised of multiple 

tasks and has a NASA Headquarters code assigned with tasks and has a NASA Headquarters code assigned with 

primary responsibility for preparing an action plan that 

will lead to an implementation plan. The responsible will lead to an implementation plan. The responsible 

NASA Headquarters code will coordinate with other NASA Headquarters code will coordinate with other 

organizations as necessary to accomplish this. The organizations as necessary to accomplish this. The 

responsible codes are:

a. Code AE – Chief Engineer Code AE – Chief Engineer

b. Code F – Human Resources

c. Code G – General Council

d. Code H – Procurement

e. Code J – Management Systems

f. Code Q – Safety and Mission Assurance Code Q – Safety and Mission Assurance

g. Code X – Security Management and Safeguards

3. The Diaz Team numbered each of the R-O-Fs with a The Diaz Team numbered each of the R-O-Fs with a 

unique identifi er as shown below: unique identifier as shown below:

a. Recommendations: R1 through R29

b. Observations: O1 through O27

c. Findings: F1 through F137

4. Each Specifi c Action is numbered sequentially 1 Each Specific Action is numbered sequentially 1 

through 40. 

5. The CAIB Report used the schema shown below to 

identify each R-O-F. identify each R-O-F.

A - 1
* Broadly Applicable

A-2

Diaz

Team # CAIB # CAIB Report Recommendations andPertinent Factors BA* Diaz Summary Discussion Specific Action Category

R1 R3.2-1 Initiate an aggressive program to

eliminate all External Tank Thermal

Protection System debris-shedding at the

source with particular emphasis on the

region where the bipod struts attach to the

External Tank. [RTF]

R2 R3.3-1 Develop and implement a comprehensive

inspection plan to determine the structural

integrity of all Reinforced Carbon-Carbon

system components. This inspection plan

should take advantage of advanced nondestructive inspection technology. [RTF]

R3 R3.3-2 Initiate a program designed to increase

the Orbiter’s ability to sustain minor

debris damage by measures such as

improved impact-resistant Reinforced

Carbon-Carbon and acreage tiles. This

program should determine the actual

impact resistance of current materials and

the effect of likely debris strikes. [RTF]

R4 R3.3-3 To the extent possible, increase the

Orbiter’s ability to successfully re-enter

the Earth’s atmosphere with minor

leading edge structural sub-system

damage.

R5 R3.3-4 In order to understand the true material

characteristics of Reinforced CarbonCarbon components, develop a

comprehensive database of flown Reinforced Carbon-Carbon material

characteristics by destructive testing and

evaluation.

R6 R3.3-5 Improve the maintenance of launch pad

structures to minimize the leaching of

zinc primer onto Reinforced CarbonCarbon components.

R7 R3.4-1 Upgrade the imaging system to be

capable of providing a minimum of three

useful views of the Space Shuttle from

liftoff to at least Solid Rocket Booster

separation, along any expected ascent

azimuth. The operational status of these

assets should be included in the Launch

Commit Criteria for future launches.

Consider using ships or aircraft to provide

additional views of the Shuttle during

ascent. [RTF]

Y While the CAIB Report focuses on the

Space Shuttle Program and a specific

area of risk, all programs need to

identify the critical means for

monitoring their systems and ensure that

the data is collected, observed, and

analyzed. Without the information,

there may be no means of identifying

potential incipient failures that could

lead to mission degradation, failure, or

loss.

1) Review/develop current policy

or guidance that assures critical

event data is collected, observed

and analyzed.

a. Review/develop a standard for

program development strategy

based on the program focus of

R&D versus operational system

or infrastructure that focuses on

the comprehensive assessment of

program management, technical,

Processes &

Rules
* Broadly Applicable

A-3

Diaz

Team # CAIB # CAIB Report Recommendations andPertinent Factors BA* Diaz Summary Discussion Specific Action Category

assets should be included in the Launch

Commit Criteria for future launches.

Consider using ships or aircraft to provide

additional views of the Shuttle during

ascent. [RTF]

analyzed. Without the information,

there may be no means of identifying

potential incipient failures that could

lead to mission degradation, failure, or

loss.

based on the program focus of

R&D versus operational system

or infrastructure that focuses on

the comprehensive assessment of

program management, technical,

and operational risks.

b. Review/develop a process to

determine appropriate means for

observing the program at all

phases where risks have been

identified along with a means of

observing, collecting, trending,

archiving, and analyzing data.

c. Review/develop a process for

program reviews that would

ensure that any changes,

degradation or improvement, in

a relied-upon system, cannot be

accomplished without the

concurrence of programs.

Responsibility: Code AE

R8 R3.4-2 Provide a capability to obtain and

downlink high-resolution images of the

External Tank after it separates. [RTF]

Y Following the rationale for R3.4-1, this

capability needs to be available for all

phases of the program’s execution,

especially during times of major

program events. Otherwise problem

resolutions may be based on guesses or

theories as opposed to hard data.

2) Develop a standard for

comprehensive program risk

management and observable data

collection for all phases of

program development, test,

operation, and enhancement to

be used for program

management, improvement,

anomaly/disaster reconstruction.

a. Similar to the Cost Analysis

Resource Document (CARD),

develop a process for a

continuously updated and

maintained program document

that details the plan for

management of program data

and ongoing anomaly resolution

activities and closeout results.

b. Develop a process for periodic

independent program review and

assessment that validates risk

areas and comprehensive

monitoring/management based

on this standard.

Processes &

Rules
* Broadly Applicable

A-4

Diaz

Team # CAIB # CAIB Report Recommendations andPertinent Factors BA* Diaz Summary Discussion Specific Action Category

areas and comprehensive

monitoring/management based

on this standard.

Responsibility: Code AE

R9 R3.4-3 Provide a capability to obtain and

downlink high-resolution images of the

underside of the Orbiter wing leading

edge and forward section of both wings'

Thermal Protection System. [RTF]

R10 R3.6-1 The Modular Auxiliary Data System

instrumentation and sensor suite on each

Orbiter should be maintained and updated

to include current sensor and data

acquisition technologies.

R11 R3.6-2 The Modular Auxiliary Data System

should be redesigned to include

engineering performance and vehicle

health information, and have the ability to

be reconfigured during flight in order to

allow certain data to be recorded,

telemetered, or both, as needs change.

R12 R3.8-1 Obtain sufficient spare Reinforced

Carbon-Carbon panel assemblies and

associated support components to ensure

that decisions related to Reinforced

Carbon-Carbon maintenance are made on

the basis of component specifications,

free of external pressures relating to

schedules, costs, or other considerations.

Y All programs, whether they are

aerospace missions or supporting

infrastructure, should make decisions on

the use of hardware without finding it

necessary to compromise on safety or

quality in the face of programmatic

pressures. Every program risk

assessment should include consideration

of the adequacy of hardware

development quantities and schedule to

assure mission success.

3) Review current policy, criteria,

and contractual guidance

regarding supply chain, sparing,

and obsolescence policy.

a. Identify whether program is

operational and amenable to Life

Cycle Cost (LCC) analysis;

identify if program provides

mission support and supports

critical mission operations.

b. Identify best practices across

other federal agencies and

commercial companies for

supply chain management for

R&D versus operations

programs (for which an LCC

analysis is applicable).

c. Develop standards and criteria

for tracking degradation of

capabilities (especially for

mission critical support items),

managing obsolescence, resupply, and refurbishment for

supply chain definition and

management.

Risk

Management
* Broadly Applicable

A-5

Diaz

Team # CAIB # CAIB Report Recommendations andPertinent Factors BA* Diaz Summary Discussion Specific Action Category

managing obsolescence, resupply, and refurbishment for

supply chain definition and

management.

d. Incorporate any new policies,

criteria or guidance into the risk

analysis process.

e. Develop standards for program

recertification based on

obsolescence and other decision

criteria such as service life

extension.

Responsibility: Code AE

R13 R3.8-2 Develop, validate, and maintain physicsbased computer models to evaluate

Thermal Protection System damage from

debris impacts. These tools should

provide realistic and timely estimates of

any impact damage from possible debris

from any source that may ultimately

impact the Orbiter. Establish impact

damage thresholds that trigger responsive

corrective action, such as on-orbit

inspection and repair, when indicated.

Y All programs should produce, maintain,

and validate models to assess the state of

their systems and components. These

models should be continually updated

and validated against experimental and

operational data to determine

appropriate courses of action and repair.

The value of the models should be

assessed with respect to their ability to

support decision making in a timely way

so as not to lead the decision maker to a

conflict between costly action versus

effective action in the interest of safety

or mission success.

4) Develop a standard for the

development, documentation,

and operation of models and

simulations.

a. Identify best practices to ensure

that knowledge of operations is

captured in the user interfaces

(e.g. users are not able to enter

parameters that are out of

bounds).

b. Develop process for tool

verification and validation,

certification, reverification,

revalidation, and recertification

based on operational data and

trending.

c. Develop standard for

documentation, configuration

management, and quality

assurance.

d. Identify any training or

certification requirements to

ensure proper operational

capabilities.

e. Provide a plan for tool

management, maintenance, and

obsolescence consistent with

modeling/simulation

environments and the aging or

changing of the modeled

platform or system.

Technical

Capabilities
* Broadly Applicable

A-6

Diaz

Team # CAIB # CAIB Report Recommendations andPertinent Factors BA* Diaz Summary Discussion Specific Action Category

changing of the modeled

platform or system.

f. Develop a process for user

feedback when results appear

unrealistic or defy explanation.

Responsibility: Code AE

R14 R4.2-1 Test and qualify the flight hardware bolt

catchers. [RTF]

R15 R4.2-2 As part of the Shuttle Service Life

Extension Program and potential 40-year

service life, develop a state-of-the-art

means to inspect all Orbiter wiring,

including that which is inaccessible.

R16 R4.2-3 Require that at least two employees

attend all final closeouts and intertank

area hand-spraying procedures. [RTF]

R17 R4.2-4 Require the Space Shuttle to be operated

with the same degree of safety for

micrometeoroid and orbital debris as the

degree of safety calculated for the

International Space Station. Change the

micrometeoroid and orbital debris safety

criteria from guidelines to requirements.

Y All programs should adopt the same

standards for risk acceptance and adopt

common methodologies for risk

assessment. Programs should look for

innovative solutions to risk mitigation

including use and support of other

agency (e.g., DoD) resources.

5) Review current policies

associated with the uniform

application of risk acceptance

for orbital operations.

a. Identify institutional standards

for requirements for debris

avoidance and protection.

b. Review liaison responsibility

with the Air Force for debris

tracking and NASA funding

support (as required) with Code

Q.

Responsibility: Code Q

Risk

Management

R18 R4.2-5 Kennedy Space Center Quality Assurance

and United Space Alliance must return to

the straightforward, industry-standard

definition of “Foreign Object Debris” and

eliminate any alternate or statistically

deceptive definitions like “processing

debris.” [RTF]

R19 R6.2-1 Adopt and maintain a Shuttle flight

schedule that is consistent with available

resources. Although schedule deadlines

are an important management tool, those

deadlines must be regularly evaluated to

ensure that any additional risk incurred to

meet the schedule is recognized,

understood, and acceptable. [RTF]

Y It has been noted that schedules are

sometimes established without an

underlying rationale and assessment of

risk. As a result, programs across

NASA may not be using schedules as

management tools but as concrete dates

for performance. NASA needs to

continually reevaluate program risk as to

whether it is acceptable given NASA

6) Develop a standard for program

development strategy based on

the program focus of R&D

versus operational system or

infrastructure that focuses on the

comprehensive assessment of

program management, technical,

and operational risks; all of these

factors must be incorporated into

Risk

Management
* Broadly Applicable

A-7

Diaz

Team # CAIB # CAIB Report Recommendations andPertinent Factors BA* Diaz Summary Discussion Specific Action Category

deadlines must be regularly evaluated to

ensure that any additional risk incurred to

meet the schedule is recognized,

understood, and acceptable. [RTF]

NASA may not be using schedules as

management tools but as concrete dates

for performance. NASA needs to

continually reevaluate program risk as to

whether it is acceptable given NASA

policy and standards. This is applicable

across all NASA programs whether they

be R&D, mission related, or

infrastructure.

infrastructure that focuses on the

comprehensive assessment of

program management, technical,

and operational risks; all of these

factors must be incorporated into

the development of an integrated

program schedule.

a. Expand upon independent

program reviews (Independent

Assessments, Independent and

Implementation Reviews) that

require re-review when any

interim major milestone slips to

determine the impact on mission

completion schedule and cost

risk.

Responsibility: Code AE

R20 R6.3-1 Implement an expanded training program

in which the Mission Management Team

faces potential crew and vehicle safety

contingencies beyond launch and ascent.

These contingencies should involve

potential loss of Shuttle or crew, contain

numerous uncertainties and unknowns,

and require the Mission Management

Team to assemble and interact with

support organizations across

NASA/Contractor lines and in various

locations. [RTF]

Y All programs should have robust training

programs that allow personnel to

practice both likely and unlikely failure

scenarios to prepare them for

contingency management. Simulations

should be a routine part of training.

This will reduce the potential response

shock and enable more effective

problem resolution and personnel

innovation at multiple organizational

levels.

7) Review current policies

associated with developing

emergency procedures and

operational contingencies and

associated training and

certification.

a. After review of policies, conduct

an audit of no less than three

programs to determine

compliance. The training

curricula should be for systems,

and programs that have

requirements for operational

support. These systems would be

on orbit, flight, underwater,

human testing, and any other

system or program that requires

any type of emergency

procedures.

b. If required, rewrite the policies

to comply with the CAIB

recommendation as a minimum.

The rewritten policies should go

beyond the CAIB

recommendation if the minimum

is not sufficient to affect the

changes needed.

Learning
* Broadly Applicable

A-8

Diaz

Team # CAIB # CAIB Report Recommendations andPertinent Factors BA* Diaz Summary Discussion Specific Action Category

is not sufficient to affect the

changes needed.

c. Upon Code AE review of the

policies associated with

emergency procedures and

operational contingencies, and

changes made as necessary in a

revision to NASA Policy

Directive (NPD) 3410,

appropriately communicate to

Center Directors and Center

training officers for compliance.

Responsibility: Code AE

R21 R6.3-2 Modify the Memorandum of Agreement

with the National Imagery and Mapping

Agency to make the imaging of each

Shuttle flight while on orbit a standard

requirement. [RTF]

Y The need to use national assets to assess

spacecraft health applies to many

programs.

8) Review the current

Memorandum of Agreement

(MOA) with the National

Imagery and Mapping Agency,

which is now called the National

Geospatial-Intelligence Agency

(NGA).

a. Expand the MOA to include

programs other than Shuttle.

b. Ensure that the proper security

clearances are maintained for

access to classified data. See

F6.3-20

Responsibility: Code G

Risk

Management

R22 R6.4-1 For missions to the International Space

Station, develop a practicable capability

to inspect and effect emergency repairs to

the widest possible range of damage to

the Thermal Protection System, including

both tile and Reinforced Carbon-Carbon,

taking advantage of the additional

capabilities available when near to or

docked at the International Space Station.

For non-Station missions, develop a

comprehensive autonomous (independent

of Station) inspection and repair

capability to cover the widest possible

range of damage scenarios.
* Broadly Applicable

A-9

Diaz

Team # CAIB # CAIB Report Recommendations andPertinent Factors BA* Diaz Summary Discussion Specific Action Category

range of damage scenarios.

Accomplish an on-orbit Thermal

Protection System inspection, using

appropriate assets and capabilities, early

in all missions.

The ultimate objective should be a fully

autonomous capability for all missions to

address the possibility that an

International Space Station mission fails

to achieve the correct orbit, fails to dock

successfully, or is damaged during or

after undocking. [RTF]

R23 R7.5-1 Establish an independent Technical

Engineering Authority that is responsible

for technical requirements and all waivers

to them, and will build a disciplined,

systematic approach to identifying,

analyzing, and controlling hazards

throughout the life cycle of the Shuttle

System. The independent technical

authority does the following as a

minimum:

Develop and maintain technical

standards for all Space Shuttle

Program projects and elements

Be the sole waiver-granting

authority for all technical

standards

Conduct trend and risk analysis

at the sub-system, system, and

enterprise levels

Own the failure mode, effects

analysis and hazard reporting

systems

Conduct integrated hazard

analysis

Decide what is and is not an

anomalous event

Independently verify launch

readiness

Approve the provisions of the

recertification program called for

in Recommendation R9.1-1

Y All programs should have the benefit of

an independent engineering authority to

ensure that technical standards are being

met. No programs should have the

ability to waive technical standards or

compromise a standard without the

review and approval of an appropriate

engineering authority. All projects and

programs should conduct risk analysis

consistent with Agency policy regarding

risk management. All Centers should

have the capability in either their

engineering or Safety and Mission

Assurance (SMA) organizations to

perform and or review failure modes and

effects analysis, and hazard analysis.

For manned and unmanned flights and

launches, Centers should establish flight,

mission, or launch readiness certification

processes that include verification by the

independent engineering and SMA

organizations. Independence is defined

as both organizational (outside the

operations, project or program structure)

as well as financial (funding allocation

decisions made or approved) at the first

organizational level that owns both the

operation, project or program and the

center engineering and SMA

organizations.

9) Develop plans for implementing

an Independent Technical

Engineering Authority (ITEA) of

the scope envisioned by the

CAIB.

a. Develop organizational

approaches that assure

independence of Safety,

Reliability, and Quality

Assurance (SR&QA) activities

and organizations.

b. Implement the ITEA

organization.

Responsibility: Code Q Organizational

Structure
* Broadly Applicable

A-10

Diaz

Team # CAIB # CAIB Report Recommendations andPertinent Factors BA* Diaz Summary Discussion Specific Action Category

recertification program called for

in Recommendation R9.1-1

The Technical Engineering Authority

should be funded directly from NASA

Headquarters, and should have no

connection to or responsibility for

schedule or program cost.

organizations.

R24 R7.5-2 NASA Headquarters Office of Safety and

Mission Assurance should have direct

line authority over the entire Space

Shuttle Program safety organization and

should be independently resourced.

Y All programs having an impact on

operational safety should have the

benefit of an independent safety

organization for assurance. This

approach supplements the in-line safety,

quality, reliability and mission assurance

efforts by providing independence from

any perceived conflicts due to program

budgets and schedules. This is

important across all programs, including

infrastructure programs that could have a

direct or indirect impact on space

vehicle mission success and safety. The

establishment of the NASA Engineering

and Safety Center (NESC) as an

enhancement to the agency’s

independent safety capability is noted

and endorsed. As in R7.5-1,

independence is defined as both

organizational and financial with respect

to the activity being served by the

assurance team.

Same as R7.5-1

Organizational

Structure

R25 R7.5-3 Reorganize the Space Shuttle Integration

Office to make it capable of integrating

all elements of the Space Shuttle

Program, including the Orbiter.

R26 R9.1-1 Prepare a detailed plan for defining,

establishing, transitioning, and

implementing an Independent Technical

Engineering Authority, independent

safety program, and a reorganized Space

Shuttle Integration Office as described in

R7.5-1, R7.5-2, and R7.5-3. In addition,

NASA should submit annual reports to

Congress, as part of the budget review

process, on its implementation activities.

[RTF]

Y NASA should address the formation of

these organizations subject to R7.5-1.

The process should allow for an orderly

transition to avoid any unintended

consequence in the process.

Same as R7.5-1

Organizational

Structure
* Broadly Applicable

A-11

Diaz

Team # CAIB # CAIB Report Recommendations andPertinent Factors BA* Diaz Summary Discussion Specific Action Category

[RTF]

R27 R9.2-1 Prior to operating the Shuttle beyond

2010, develop and conduct a vehicle

recertification at the material, component,

subsystem, and system levels.

Recertification requirements should be

included in the Service Life Extension

Program.

R28 R10.3-1 Develop an interim program of closeout

photographs for all critical sub-systems

that differ from engineering drawings.

Digitize the closeout photograph system

so that images are immediately available

for on-orbit troubleshooting. [RTF]

Y All programs should maintain a log and

photographic record of all critical sub

system modifications and their

engineering drawings to ensure real-time

access to the latest configurations for

configuration management and problem

resolution. This will help reduce the

time and cost to reconstruct the current

system configuration whether it be on

orbit, in a ground station, or in a

laboratory.

10) Review current policies and

capabilities associated with

configuration control, closeout

photographs, and engineering

drawings. Determine if the

policies if implemented, meet

the intent of the CAIB

recommendation.

a. After review of policies, conduct

an audit of no less than three

programs to determine

compliance. If the programs are

compliant, determine if the

methods used are adequate.

b. If required, rewrite the policies

to comply with the CAIB

recommendation as a minimum.

The rewritten policies should go

beyond the CAIB

recommendation if the minimum

is not sufficient to affect the

changes needed.

Responsibility: Code AE

Technical

Capabilities

R29 R10.3-2 Provide adequate resources for a longterm program to upgrade the Shuttle

engineering drawing system including:

Reviewing drawings for

accuracy

Converting all drawings to a

computer-aided drafting system

Incorporating engineering

changes

Y Accurate, comprehensive, up-to-date

engineering drawings should be

maintained for all programs. All

programs should have adequate

resources to maintain a drawing system

that is Computer-Aided Design (CAD)

based and can incorporate engineering

changes.

Same as R10.3-1

Technical

Capabilities
* Broadly Applicable

A-12

Diaz

Team # CAIB # CAIB Report Recommendations andPertinent Factors BA* Diaz Summary Discussion Specific Action Category

O1 O10.1-1 NASA should develop and implement a

public risk acceptability policy for launch

and re-entry of space vehicles and

unmanned aircraft.

Y The FAA and DoD both have policies

that require public risk analyses for

programs under their purview. NASA

does and should continue to do this as

well if there is any issue of public risk

through launch or reentry of a vehicle,

over-flight of an aerodynamic test

vehicle, or handling/transportation of

material that could lead to public risk.

11) Review current policies

associated with public risk on

launch, overflight, end of life

reenentry of previously manned

or robotic spacecraft, and

recovery of any NASA asset as

well as the handling and

transportation of hazardous

materials. Determine if the

policies, if implemented, meet

the intent of the CAIB

recommendation.

a. NASA should consider Federal

and commercial best practices

with respect to public risk

management to determine if any

policies and practices are

applicable and transferable to

NASA.

b. After Review of Policies,

conduct an audit of no less than

three programs to determine

compliance. If the programs are

compliant, determine if the

methods used are adequate.

c. If required, rewrite the policies

to comply with the CAIB

recommendation as a minimum.

The rewritten policies should go

beyond the CAIB

recommendation if the minimum

is not sufficient to affect the

changes needed.

Responsibility: Code Q

Risk

Management

O2 O10.1-2 NASA should develop and implement a

plan to mitigate the risk that Shuttle

flights pose to the general public.

O3 O10.1-3 NASA should study the debris recovered

from Columbia to facilitate realistic

estimates of the risk to the public during

Orbiter re-entry.
* Broadly Applicable

A-13

Diaz

Team # CAIB # CAIB Report Recommendations andPertinent Factors BA* Diaz Summary Discussion Specific Action Category

O4 O10.2-1 Future crewed-vehicle requirements

should incorporate the knowledge gained

from the Challenger and Columbia

accidents in assessing the feasibility of

vehicles that could ensure crew survival

even if the vehicle is destroyed.

O5 O10.4-1 Perform an independently led, bottom-up

review of the Kennedy Space Center

Quality Planning Requirements

Document to address the entire quality

assurance program and its administration.

This review should include development

of a responsive system to add or delete

government mandatory inspections.

O6 O10.4-2 Kennedy Space Center’s Quality

Assurance programs should be

consolidated under one Mission

Assurance office, which reports to the

Center Director.

O7 O10.4-3 Kennedy Space Center quality assurance

management must work with NASA and

perhaps the Department of Defense to

develop training programs for its

personnel.

O8 O10.4-4 Kennedy Space Center should examine

which areas of International Organization

for Standardization 9000/9001 truly apply

to a 20-year-old research and

development system like the Space

Shuttle.

Y NASA programs should assess whether

programs are operational or inherently

R&D and then determine the

applicability of standardization and

certification processes.

12) Review current initiatives for

International Standards

Organization (ISO) and Software

Engineering Institute

Capabilities Maturity Model

(SEI CMM) across the agency to

determine if they are meeting the

objectives of NASA and are cost

and operationally effective.

a. Develop a policy that is NASA

wide on the use of initiatives like

ISO and SEI CMM.

Responsibility: Code AE

Processes &

Rules

O9 O10.5-1 Quality and Engineering review of work

documents for STS-114 should be

accomplished using statistical sampling to

ensure that a representative sample is

evaluated and adequate feedback is

communicated to resolve documentation

problems.

Y Program audits and random checks of

documentation, subject to the rigors of

statistical significance, are advised

including feedback to those appropriate.

13) Review current policies program

and technical audits across

NASA. Determine if the

policies if implemented meet the

intent of the CAIB

recommendation.

Processes &

Rules
* Broadly Applicable

A-14

Diaz

Team # CAIB # CAIB Report Recommendations andPertinent Factors BA* Diaz Summary Discussion Specific Action Category

evaluated and adequate feedback is

communicated to resolve documentation

problems.

intent of the CAIB

recommendation.

a. Conduct an audit of no less than

three programs using statistical

sampling techniques.

b. Compile the results: develop a

recommendation on conducting

routine and random audits of all

NASA programs, to include

adequate feedback to those

responsible for resolving

problems.

c. Develop or rewrite a policy for

conducting audits.

Responsibility: Code AE

O10 O10.5-2 NASA should implement United Space

Alliance’s suggestions for process

improvement, which recommend

including a statistical sampling of all

future paperwork to identify recurring

problems and implement corrective

actions.

O11 O10.5-3 NASA needs an oversight process to

statistically sample the work performed

and documented by United Space

Alliance technicians to ensure process

control, compliance, and consistency.

Y All NASA oversight processes should

include statistical sampling of performed

work and statistical data analysis to

assure integrity of processes and

hardware.

Same as O10.5-1

Processes &

Rules

O12 O10.6-1 The Space Shuttle Program Office must

make every effort to achieve greater

stability, consistency, and predictability

in Orbiter Major Modification planning,

scheduling, and work standards

(particularly in the number of modifications). Endless changes create

unnecessary turmoil and can adversely

impact quality and safety.

O13 O10.6-2 NASA and United Space Alliance

managers must understand workforce and

infrastructure requirements, match them

against capabilities, and take actions to

avoid exceeding thresholds.

Y All NASA managers must maintain a

constant awareness of workforce and

facility requirements and match them

against capabilities and take action when

exceeding thresholds.

14) Identify policies associated with

workforce and infrastructure/

facilities management and

obsolescence.

a. Conduct an agency-wide audit of

infrastructure backlog

maintenance and repair; identify

which programs they support,

and whether they have mission

critical functions.

Leadership
* Broadly Applicable

A-15

Diaz

Team # CAIB # CAIB Report Recommendations andPertinent Factors BA* Diaz Summary Discussion Specific Action Category

maintenance and repair; identify

which programs they support,

and whether they have mission

critical functions.

b. Conduct an audit of no less than

three programs using available

cost and staffing levels to

determine if the programs are

balancing the available

workforce and infrastructure

against capabilities and

schedules. Determine if the

programs are using any type of

scheduling, or workforce

allocation tools.

c. Determine if existing tools such

as the workforce planning and

analysis website, the Agency

competency management

system, and the Agency master

planning/infrastructure tools can

be used to improve workforce

and infrastructure planning.

d. Compile the results of above;

develop a recommendation(s).

e. If required, develop policy

(linkage) between workforce

planning and infrastructure

tools/policies and the set of

minimum thresholds that shall

be met.

Responsibility: Code J

O14 O10.6-3 NASA should continue to work with the

U.S. Air Force, particularly in areas of

program management that deal with aging

systems, service life extension, planning

and scheduling, workforce management,

training, and quality assurance.

Y Other organizations with similar and

dissimilar research and development and

large systems operational experience

have best practices and lessons learned

that could be of value to NASA program

management.

15) Form a workgroup to benchmark

best practices from Federal

agencies (e.g., DoD, FAA,

DOE), and commercial

industries.

a. Compile the results; establish a

permanent working group to

address common issues, and a

senior leadership group to

oversee its functioning.

Leadership
* Broadly Applicable

A-16

Diaz

Team # CAIB # CAIB Report Recommendations andPertinent Factors BA* Diaz Summary Discussion Specific Action Category

b. Develop or rewrite policies that

implement these best practices.

Responsibility: Code AE

O15 O10.6-4 The Space Shuttle Program Office must

determine how it will effectively meet the

challenges of inspecting and maintaining

an aging Orbiter fleet before lengthening

Orbiter Major Maintenance intervals.

O16 O10.7-1 Additional and recurring evaluation of

corrosion damage should include nondestructive analysis of the potential

impacts on structural integrity.

O17 O10.7-2 Long-term corrosion detection should be

a funding priority.

O18 O10.7-3 Develop non-destructive evaluation

inspections to find hidden corrosion.

O19 O10.7-4 Inspection requirements for corrosion due

to environmental exposure should first

establish corrosion rates for Orbiterspecific environments, materials, and

structural configurations. Consider

applying Air Force corrosion prevention

programs to the Orbiter.

O20 O10.8-1 Teflon (material) and Molybdenum

Disulfide (lubricant) should not be used

in the carrier panel bolt assembly.

O21 O10.8-2 Galvanic coupling between aluminum

and steel alloys must be mitigated.

O22 O10.8-3 The use of Room Temperature

Vulcanizing 560 and Koropon should be

reviewed.

O23 O10.8-4 Assuring the continued presence of

compressive stresses in A-286 bolts

should be part of their acceptance and

qualification procedures.

O24 O10.9-1 NASA should consider a redesign of the

system, such as adding a cross-strapping

cable, or conduct advanced testing for

intermittent failure.

O25 O10.10-1 NASA should reinstate a safety factor of

1.4 for the Attachment Rings—which

invalidates the use of ring serial numbers

16 and 15 in their present state—and

replace all deficient material in the

Attachment Rings.

Y Design and safety factors have been

developed by many engineering and

manufacturing organizations with a

broad base of underlying test and

supporting data.

16) Review current policies and

waivers on safety factors.

Risk

Management
* Broadly Applicable

A-17

Diaz

Team # CAIB # CAIB Report Recommendations andPertinent Factors BA* Diaz Summary Discussion Specific Action Category

invalidates the use of ring serial numbers

16 and 15 in their present state—and

replace all deficient material in the

Attachment Rings.

manufacturing organizations with a

broad base of underlying test and

supporting data.

a. Conduct an audit of no less than

three programs. Determine if

the programs are using a 1.4

safety factor, and what waivers

have been granted.

b. Compile the results and develop

a recommendation.

c. If required, develop or rewrite a

policy for minimum safety

factors, and associated waivers.

Responsibility: Code AE

O26 O10.11-1 Assess NASA and contractor equipment

to determine if an upgrade will provide

the reliability and accuracy needed to

maintain the Shuttle through 2020. Plan

an aggressive certification program for

replaced items so that new equipment can

be put into operation as soon as possible.

O27 O10.12-1 NASA should implement an agency-wide

strategy for leadership and management

training that provides a more consistent

and integrated approach to career

development. This strategy should

identify the management and leadership

skills, abilities, and experiences required

for each level of advancement. NASA

should continue to expand its leadership

development partnerships with the

Department of Defense and other external

organizations.

Y Succession planning, leadership training,

and personnel enrichment are standard

business practices in many organizations

including NASA. Review and

continuous improvement through

benchmarking with other organizations

is advised. Opportunities to expand

NASA leadership perspectives by

participation in external leadership

programs should be encouraged

throughout the agency.

17) Review current training

strategy/policies on

management, leadership, and

exchange programs used by

government and commercial

industry (including NASA

contractors) for best practices.

a. Identify programs, both federal

and commercial, for professional

enrichment.

b. Review/develop standards for

advancement in grade based on

leadership skills, technical

abilities, and operational

experience.

c. Develop a recommendation for

new or improved training

programs that address

leadership.

d. Develop or rewrite the

strategy/policy for leadership

and management training.

Responsibility: Code F

Leadership
* Broadly Applicable

A-18

Diaz

Team # CAIB # CAIB Report Recommendations andPertinent Factors BA* Diaz Summary Discussion Specific Action Category

F1 F3.2-1 NASA does not fully understand the

mechanisms that cause foam loss on

almost all flights from larger areas of

foam coverage and from areas that are

sculpted by hand.

F2 F3.2-2 There are no qualified non-destructive

evaluation techniques for the as-installed

foam to determine the characteristics of

the foam before flight.

Y Programs need to have sufficient testing

methodologies to determine that design

requirements are met and that product

performance is verified prior to NASA

acceptance.

18) Review current policy, criteria,

and contractual guidance

regarding government

acceptance.

a. Identify best practices across

other federal agencies and

commercial companies.

b. Develop standards for

acceptance testing and

performance verification.

c. Develop and specify suitable

inspection techniques for all

critical manufacturing processes.

Responsibility: Code H

Technical

Capabilities

F3 F3.2-3 Foam loss from an External Tank is

unrelated to the tank’s age and to its total

pre-launch exposure to the elements.

Therefore, the foam loss on STS-107 is

unrelated to either the age or exposure of

External Tank 93 before launch.

F4 F3.2-4 The Board found no indications of

negligence in the application of the

External Tank Thermal Protection

System.

F5 F3.2-5 The Board found instances of left bipod

ramp shedding on launch that NASA was

not aware of, bringing the total known

left bipod ramp shedding events to 7 out

of 72 missions for which imagery of the

launch or External Tank separation is

available.

Y Adequate development of root cause

determination requires that there be a

detailed understanding of whether a

failure is an anomaly or systemic.

19) Review procedures for anomaly

identification and

characterization.

a. Develop a protocol to assess the

review of past performance to

determine the incidence of

identical or related anomalies.

b. Develop an escalation procedure

based on mission criticality.

c. Develop closeout process for

root cause determination and

anomaly mitigation.

Processes &

Rules
* Broadly Applicable

A-19

Diaz

Team # CAIB # CAIB Report Recommendations andPertinent Factors BA* Diaz Summary Discussion Specific Action Category

Responsibility: Code Q

F6 F3.2-6 Subsurface defects were found during the

dissection of three bipod foam ramps,

suggesting that similar defects were likely

present in the left bipod ramp of External

Tank 93 used on STS-107.

F7 F3.2-7 Foam loss occurred on more than 80

percent of the 79 missions for which

imagery was available to confirm or rule

out foam loss.

Y Trend analysis needs to be correlated

with program requirements for

determination of anomalous or

systematic problems.

See F3.2-5.

Processes &

Rules

F8 F3.2-8 Thirty percent of all missions lacked

sufficient imagery to determine if foam

had been lost.

Y Anomalies cannot be addressed if they

are not observed. This spans all NASA

programs.

See F3.2-5 and R3.4-1. Processes &

Rules

F9 F3.2-9 Analysis of numerous separate variables

indicated that none could be identified as

the sole initiating factor of bipod foam

loss. The Board therefore concludes that a

combination of several factors resulted in

bipod foam loss.

F10 F3.3-1 The original design specifications

required the RCC components to have

essentially no impact resistance.

F11 F3.3-2 Current inspection techniques are not

adequate to assess structural integrity of

the RCC components.

Y Acceptance programs must be well

defined and robust.

See F3.2-2 Technical

Capabilities

F12 F3.3-3 After manufacturer’s acceptance nondestructive evaluation, only periodic

visual and touch tests are conducted.

Y NASA needs to ensure appropriate InService Inspection activities are taking

place for high-risk areas of repetitive

missions.

20) Review current policy for

obsolescence determination,

system maintenance, and

adherence to manufacturer’s

warranty.

a. Identify life-cycle management

and inspection practices at other

select federal agencies and

commercial enterprises.

b. Develop standards for

nondestructive evaluations of

systems and maintenance

standards to ensure that

performance is not degraded

below acceptance levels.

c. Develop standards defining

robust supply chains to ensure

that component availability does

not compromise maintenance

standards.

Risk

Management
* Broadly Applicable

A-20

Diaz

Team # CAIB # CAIB Report Recommendations andPertinent Factors BA* Diaz Summary Discussion Specific Action Category

robust supply chains to ensure

that component availability does

not compromise maintenance

standards.

Responsibility: Code AE

F13 F3.3-4 RCC components are weakened by mass

loss caused by oxidation within the

substrate, which accumulates with age.

The extent of oxidation is not directly

measurable, and the resulting mission life

reduction is developed analytically.

F14 F3.3-5 To date, only two flown RCC panels,

having achieved 15 and 19 missions, have

been destructively tested to determine

actual loss of strength due to oxidation.

F15 F3.3-6 Contamination from zinc leaching from a

primer under the paint topcoat on the

launch pad structure increases the

opportunities for localized oxidation.

F16 F3.4-1 Photographic evidence during ascent

indicates the projectile that struck the

Orbiter was the left bipod ramp foam.

F17 F3.4-2 The same photographic evidence,

confirmed by independent analysis,

indicates the projectile struck the

underside of the leading edge of the left

wing in the vicinity of RCC panels 6

through 9 or the tiles directly behind, with

a velocity of approximately 775 feet per

second.

F18 F3.4-3 There is a requirement to obtain and

downlink on-board engineering quality

imaging from the Shuttle during launch

and ascent.

Y Anomalies can occur during all phases

of a mission or operation but cannot be

adequately resolved without an ability to

observe the performance and

communicate the information.

21) Identify methods used by other

test organizations to perform

remote system testing and

anomaly resolution.

a. Develop a practice and standard

for the determination of baseline

observables and telemetry for

anomaly sampling, resolution,

and detection.

b. Perform a comparison of data

requirements against available

sensor and communications

capabilities.

Technical

Capabilities
* Broadly Applicable

A-21

Diaz

Team # CAIB # CAIB Report Recommendations andPertinent Factors BA* Diaz Summary Discussion Specific Action Category

sensor and communications

capabilities.

c. Identify shortfalls and mitigation

requirements in communications

architecture to mitigate

shortfalls, if possible.

d. Develop communications

protocols and escalation

procedures for anomaly

resolution.

e. Develop notification procedures

for up/down escalation chain and

horizontal communications

integration.

Responsibility: Code AE

F19 F3.4-4 The current long-range camera assets on

the Kennedy Space Center and Eastern

Range do not provide best possible

engineering data during Space Shuttle

ascents.

Y Observation capabilities for anomaly

detection need to have the appropriate

resolution and data rates for information

gathering and transfer.

See F3.4-3

Technical

Capabilities

F20 F3.4-5 Evaluation of STS-107 debris impact was

hampered by lack of high resolution, high

speed cameras (temporal and spatial

imagery data).

Y Observation of anomalies whether it be

on the Space Shuttle, a deep space

probe, a ground system, etc... cannot be

accomplished without a calculation of

the requirements for resolution and

sampling

See F3.4-3

Technical

Capabilities

F21 F3.4-6 Despite the lack of high quality visual

evidence, the information available about

the foam impact during the mission was

adequate to determine its effect on both

the thermal tiles and RCC.

F22 F3.5-1 The object seen on orbit with Columbia

on Flight Day 2 through 4 matches the

radar cross-section and area-to-mass

measurements of an RCC panel fragment.

F23 F3.5-2 Though the Board could not positively

identify the Flight Day 2 object, the U.S.

Air Force exclusionary test and analysis

processes reduced the potential Flight

Day 2 candidates to an RCC panel

fragment.
* Broadly Applicable

A-22

Diaz

Team # CAIB # CAIB Report Recommendations andPertinent Factors BA

* Diaz Summary Discussion Specific Action Category

fragment.

F24 F3.6-1 The de-orbit burn and re-entry flight path

were normal until just before Loss of

Signal.

F25 F3.6-2 Columbia re-entered the atmosphere with

a pre-existing breach in the left wing.

F26 F3.6-3 Data from the Modular Auxiliary Data

System recorder indicates the location of

the breach was in the RCC panels on the

left wing leading edge.

F27 F3.6-4 Abnormal heating events preceded

abnormal aerodynamic events by several

minutes.

F28 F3.6-5 By the time data indicating problems was

telemetered to Mission Control Center,

the Orbiter had already suffered damage

from which it could not recover.

F29 F3.7-1 Multiple indications from the debris

analysis establish the point of heat

intrusion as RCC panel 8-left.

F30 F3.7-2 The recovery of debris from the ground

and its reconstruction was critical to

understanding the accident scenario.

F31 F3.8-1 The impact test program demonstrated

that foam can cause a wide range of

impact damage, from cracks to a 16- by

17-inch hole.

F32 F3.8-2 The wing leading edge Reinforced

Carbon-Carbon composite material and

associated support hardware are

remarkably tough and have impact

capabilities that far exceed the minimal

impact resistance specified in their

original design requirements.

Nevertheless, these tests demonstrate that

this inherent toughness can be exceeded

by impacts representative of those that

occurred during Columbia’s ascent.

F33 F3.8-3 The response of the wing leading edge to

impacts is complex and can vary greatly,

depending on the location of the impact,

projectile mass, orientation, composition,

and the material properties of the panel

assembly, making analytic predictions of

damage to RCC assemblies a challenge.17
* Broadly Applicable

A-23

Diaz

Team # CAIB # CAIB Report Recommendations andPertinent Factors BA* Diaz Summary Discussion Specific Action Category

and the material properties of the panel

assembly, making analytic predictions of

damage to RCC assemblies a challenge.17

F34 F3.8-4 Testing indicates the RCC panels and Tseals have much higher impact resistance

than the design specifications call for.

F35 F3.8-5 NASA has an inadequate number of spare

Reinforced Carbon-Carbon panel

assemblies.

Y Programs should develop robust supply

chains based on detailed analysis of

logistics requirements and failure

analyses.

22) Review current policy, criteria,

and contractual guidance

regarding supply chain, sparing,

and obsolescence policy.

a. Identify whether program is

operational and amenable to

LCC analysis.

b. Identify best practices across

other federal agencies and

commercial companies for

supply chain management for

R&D versus operations

programs (for which an LCC

analysis is applicable).

c. Develop standards and criteria

for managing obsolescence, resupply, and refurbishment for

supply chain definition and

management.

Responsibility: Code AE

Risk

Management

F36 F3.8-6 NASA's current tools, including the

CRATER model, are inadequate to

evaluate Orbiter Thermal Protection

System damage from debris impacts

during pre-launch, on-orbit, and postlaunch activity.

Y Same as R3.8-2 See R3.8-2

Technical

Capabilities

F37 F3.8-7 The bipod ramp foam debris critically

damaged the leading edge of Columbia’s

left wing.

F38 F4.2-1 The certification of the bolt catchers

flown on STS-107 was accomplished by

extrapolating analysis done on similar but

not identical bolt catchers in original

testing. No testing of flight hardware was

performed.

Y Historically there have been instances of

inappropriate application of similarity as

the criterion for hardware verification.

The Agency should strengthen its

instruction in the use of similarity as a

verification method.

23) Develop a standard for the

modeling and testing (both

destructive and nondestructive)

of system components and

assemblies.

a. Identify best practices to ensure

that knowledge of operations

and trend data is captured and

incorporated into test

procedures.

Technical

Capabilities
* Broadly Applicable

A-24

Diaz

Team # CAIB # CAIB Report Recommendations andPertinent Factors BA* Diaz Summary Discussion Specific Action Category

that knowledge of operations

and trend data is captured and

incorporated into test

procedures.

b. Develop process for component

test verification, validation,

certification, reverification,

revalidation, and recertification

based on operational data and

trending against component and

assembly design specifications.

c. Develop escalation process for

communicating results of critical

mission importance.

d. Develop process for

incorporation of test data into

supply chain management

process.

Responsibility: Code AE

F39 F4.2-2 Board-directed testing of a small sample

size demonstrated that the “as-flown” bolt

catchers do not have the required 1.4

margin of safety.

Y Periodic testing of program

subassemblies and components should

occur to determine whether or not design

specifications have been compromised;

this data is valid in supporting supply

chain analyses.

See F4.2-1

Technical

Capabilities

F40 F4.2-3 Quality assurance processes for bolt

catchers (a Criticality 1 subsystem) were

not adequate to assure contract

compliance or product adequacy.

F41 F4.2-4 An unknown metal object was seen

separating from the stack during Solid

Rocket Booster separation during six

Space Shuttle missions. These objects

were not identified, but were characterized as of little to no concern.

Y Unknown anomalies should be

considered a problem unless proven

otherwise.

24) Identify clear chains of

command in a program

including responsibility,

accountability, and authority for

issue communications.

a. Develop escalation process for

communicating information of

critical mission importance.

b. Develop communications

process up/down escalation path,

which also considers horizontal

communications integration and

informal channels of input.

Communication
* Broadly Applicable

A-25

Diaz

Team # CAIB # CAIB Report Recommendations andPertinent Factors BA* Diaz Summary Discussion Specific Action Category

c. Develop independent conflict

resolution process for anomaly

mediation and resolution, as

required.

Responsibility: Code AE

F42 F4.2-5 Based on the extensive wiring

inspections, maintenance, and

modifications prior to STS-107, analysis

of sensor/wiring failure signatures, and

the alignment of the signatures with

thermal intrusion into the wing, the Board

found no evidence that Kapton wiring

problems caused or contributed to this

accident.

F43 F4.2-6 Crushed foam does not appear to have

contributed to the loss of the bipod foam

ramp off the External Tank during the

ascent of STS-107.

F44 F4.2-7 The hypergolic spill was not a factor in

this accident.

F45 F4.2-8 Space weather was not a factor in this

accident.

F46 F4.2-9 A “rough wing” was not a factor in this

accident.

F47 F4.2-10 The Board concludes that training and onorbit considerations were not factors in

this accident.

F48 F4.2-11 The payloads Columbia carried were not

a factor in this accident.

F49 F4.2-12 The Board found no evidence that willful

damage was a factor in this accident.

F50 F4.2-13 Two close-out processes at the Michoud

Assembly Facility are currently able to be

performed by a single person.

F51 F4.2-14 Photographs of every close out activity

are not routinely taken.

Y Best practices from commercial aviation

and nuclear power plants are applicable

to NASA operations to provide complete

documentation if necessary.

25) Identify programs of similar

nature with applicable practices

for such activities as closeout

photographs, program

documentation and configuration

management to NASA

operational and R&D initiatives.

Technical

Capabilities
* Broadly Applicable

A-26

Diaz

Team # CAIB # CAIB Report Recommendations andPertinent Factors BA* Diaz Summary Discussion Specific Action Category

a. Develop program case studies of

best practices for analysis of

problems, solutions, and results

from applicable programs.

b. Develop standards based on

researched best practices for

NASA operational and R&D

programs.

c. Develop publications and

continued training to ensure the

dissemination of information to

NASA and contractor personnel.

d. Update and expand as necessary.

Responsibility: Code AE

F52 F4.2-15 There is little evidence that Columbia

encountered either micrometeoroids or

orbital debris on this flight.

F53 F4.2-16 The Board found markedly different

criteria for margins of micrometeoroid

and orbital debris safety between the

International Space Station and the

Shuttle.

Y Risk determination needs to be

uniformly applied across NASA.

Programs should have standards for risk

acceptance.

See R4.2-4

Risk

Management

F54 F4.2-17 Based on a thorough investigation of

maintenance records and interviews with

maintenance personnel, the Board found

no errors during Columbia’s most recent

Orbiter Major Modification that contributed to the accident.

F55 F4.2-18 Since 2001, Kennedy Space Center has

used a non-standard approach to define

foreign object debris. The industry

standard term “Foreign Object Damage”

has been divided into two categories, one

of which is much more permissive.

F56 F6.1-1 NASA has not followed its own rules and

requirements on foam-shedding.

Although the agency continuously

worked on the foam-shedding problem,

the debris impact requirements have not

been met on any mission.

Y Independent audits need to be conducted

to identify any deviations from

adherence to specifications.

26) Review a minimum of three

programs to determine if they

are “Following the Rules.”

a. Conduct an awareness campaign

on the need to “follow the rules”

for requirements imposed by

programs.

Processes &

Rules
* Broadly Applicable

A-27

Diaz

Team # CAIB # CAIB Report Recommendations andPertinent Factors BA* Diaz Summary Discussion Specific Action Category

programs.

b. Rewrite policy or practice if

required.

Responsibility: Code AE

F57 F6.1-2 Foam-shedding, which had initially raised

serious safety concerns, evolved into “infamily” or “no safety-of-flight” events or

were deemed an “accepted risk.”

Y An independent organization should

identify deviations from program

requirements. Unless a requirement is

determined as an over-specification and

formally waived, any deviation from a

design requirement should not be

relegated to a lower status. Program

Managers should be careful to avoid

“normalization of deviance.”

27) Develop a standard and process

for independent review of all

program requirements and

operational constraints for

consistency and identify all

program waivers.

a. Conduct an analysis of the

history of program anomalies

and resolution actions and

identify all changes in status

consistent with the normalization

of deviance.

b. Develop course of action to

reconcile any deficiencies and

refocus on root cause analysis,

and anomaly resolution as it

relates directly to program

requirements.

c. Develop a plan for periodic,

independent program reviews.

Responsibility: Code AE

Organizational

Structure

F58 F6.1-3 Five of the seven bipod ramp events

occurred on missions flown by Columbia,

a seemingly high number. This

observation is likely due to Columbia

having been equipped with umbilical

cameras earlier than other Orbiters.

F59 F6.1-4 There is lack of effective processes for

feedback or integration among project

elements in the resolution of In-Flight

Anomalies.

Y NASA has many large and complex

programs that likely have similar

communications and organizational

problems. Feedback mechanisms and

processes should be established for all

programs to ensure that in-flight

anomalies are resolved.

28) Develop a clear process for

management chain of command

and communications within a

program and among government

organizations and program

management/contractor

interfaces for anomaly request

and resolution.

a. Develop streamlined and rapid

escalation process for

communicating information of

critical mission importance

Leadership
* Broadly Applicable

A-28

Diaz

Team # CAIB # CAIB Report Recommendations andPertinent Factors BA* Diaz Summary Discussion Specific Action Category

communicating information of

critical mission importance

b. Develop communications

process up/down escalation path,

which also provides for

horizontal and informal

communications integration.

c. Develop independent conflict

resolution process for anomaly

mediation and resolution that

would stop “normalization of

deviance”.

d. Develop a website and hotline

for the reporting of program

concerns for third parties.

Appropriate escalation

procedures need to be

determined for timely

notification.

e. Provide training and assistance if

needed.

Responsibility: Code AE

F60 F6.1-5 Foam bipod debris-shedding incidents on

STS-52 and STS-62 were undetected at

the time they occurred, and were not

discovered until the Board directed

NASA to examine External Tank separation images more closely.

F61 F6.1-6 Foam bipod debris-shedding events were

classified as In-Flight Anomalies up until

STS-112, which was the first known

bipod foam-shedding event not classified

as an In-Flight Anomaly.

Y An independent organization should

identify all deviations from program

requirements. Unless a requirement is

determined as an over-specification and

formally waived, any deviation from a

design requirement should not be

relegated to a lower status.

See F6.1-2

Organizational

Structure

F62 F6.1-7 The STS-112 assignment for the External

Tank Project to “identify the cause and

corrective action of the bipod ramp foam

loss event” was not due until after the

planned launch of STS-113, and then

slipped to after the launch of STS-107.

F63 F6.1-8 No External Tank configuration changes

were made after the bipod foam loss on

STS-112.
* Broadly Applicable

A-29

Diaz

Team # CAIB # CAIB Report Recommendations andPertinent Factors BA* Diaz Summary Discussion Specific Action Category

were made after the bipod foam loss on

STS-112.

F64 F6.1-9 Although it is sometimes possible to

obtain imagery of night launches because

of light provided by the Solid Rocket

Motor plume, no imagery was obtained

for STS-113.

F65 F6.1-10 NASA failed to adequately perform trend

analysis on foam losses. This greatly

hampered the agency’s ability to make

informed decisions about foam losses.

Y All anomalies must be captured, well

documented and researched to determine

if they represent unique or systemic

problems.

29) Develop a standard and process

for anomaly identification,

trending, classification, tracking,

and resolution management.

a. Develop a process for root cause

analysis, resolution, and

documentation.

b. Perform at least 3 program

audits to assure compliance with

standards.

c. Develop a standard for the

periodic independent review of

this process.

Responsibility: Code AE

Risk

Management

F66 F6.1-11 Despite the constant shedding of foam,

the Shuttle Program did little to harden

the Orbiter against foam impacts through

upgrades to the Thermal Protection

System. Without impact resistance and

strength requirements that are calibrated

to the energy of debris likely to impact

the Orbiter, certification of new Thermal

Protection System tile will not adequately

address the threat posed by debris.

F67 F6.2-1 NASA Headquarters’ focus was on the

Node 2 launch date, February 19, 2004.

Y Executive management’s decisions will

benefit from a better understanding of

program milestones and associated

changing risks before casting schedules

in stone. They should not force

decisions to be schedule-driven without

understanding the implications.

30) Expand upon the process for

independent program reviews

(Independent Assessments,

Independent Implementation

Reviews, and Non-Advocate

Reviews) that require re-review

when any interim major

milestone slips to determine the

impact on mission completion

schedule and cost risk.

Leadership
* Broadly Applicable

A-30

Diaz

Team # CAIB # CAIB Report Recommendations andPertinent Factors BA* Diaz Summary Discussion Specific Action Category

Responsibility: Code AE

F68 F6.2-2 The intertwined nature of the Space

Shuttle and Space Station programs

significantly increased the complexity of

the schedule and made meeting the

schedule far more challenging.

Y NASA programs should be managed

with an Agency-wide system and

operational optimization perspective.

This applies to both operational and

infrastructure programs.

31) Perform a comprehensive

assessment of major program

interdependencies.

a. Analyze the data from the

Integrated Financial

Management Program (IFMP) to

cross check this analysis in terms

of perception and reality.

b. Develop an assessment of the

full cost implications of

individual program requirements

changes on other programs to

ensure that cost- effective

decisions are the result.

c. Identify cross-programmatic

dependencies and crossprogrammatic risk factors.

d. Each program should identify its

own interdependencies, which

are recognized in the program

plans and risk assessments.

e. Reevaluate individual program

requirements based on this

analysis.

Responsibility: Code AE

Organizational

Structure

F69 F6.2-3 The capabilities of the system were being

stretched to the limit to support the

schedule. Projections into 2003 showed

stress on vehicle processing at the

Kennedy Space Center, on flight

controller training at Johnson Space

Center, and on Space Station crew

rotation schedules. Effects of this stress

included neglecting flight controller

recertification requirements, extending

crew rotation schedules, and adding

incremental risk by scheduling additional

Orbiter movements at Kennedy.

Y NASA needs to audit its staffing

practices and workforce management

practices in terms of surge and

certifications. Data needs to be

provided to executive management

regarding personnel burnout, loss of

certifications, errors, etc., so that

executives can make appropriate

determinations.

32) Develop a clear process for

management chain of command

for program management.

a. Identify clear requirements for

advancement or reassignment to

positions in terms of required

training and skill, not simply

meeting minimum qualification

standards.

b. Develop a standard for the

application of overtime and

surge duration based on

demonstrated industry best

practices for other Federal

agencies and similar commercial

enterprises.

Leadership
* Broadly Applicable

A-31

Diaz

Team # CAIB # CAIB Report Recommendations andPertinent Factors BA* Diaz Summary Discussion Specific Action Category

c. Develop a standard for

requirements for certifications

and a notification method for

employee recertification and

training.

d. Review and modify NASA

policies and practices concerning

staffing, workforce management,

and certifications.

e. Conduct an audit of at least three

programs for compliance.

Responsibility: Code AE

F70 F6.2-4 The four flights scheduled in the five

months from October 2003, to February

2004, would have required a processing

effort comparable to the effort

immediately before the Challenger accident.

F71 F6.2-5 There was no schedule margin to

accommodate unforeseen problems.

When flights come in rapid succession,

there is no assurance that anomalies on

one flight will be identified and

appropriately addressed before the next

flight.

Y All programs including those associated

with NASA infrastructure should allow

adequate schedule margin to

accommodate unforeseen problems.

33) Perform an assessment of best

industry practices for R&D,

completion, and operational

programs to assess the

management of schedule and

cost risk through the

development of management

reserves.

a. Perform an assessment of the

planned versus actual time and

cost transition across

Technology Readiness Levels

(TRL) to benchmark NASA

performance against other

federal agencies.

b. Develop a standard associated

with program development and

planning that incorporates

independent reviews.

Responsibility: Code AE

Leadership

F72 F6.2-6 The environment of the countdown to

Node 2 and the importance of

maintaining the schedule may have begun

to influence managers' decisions,

including those made about the STS-112

foam strike.

Y Minority views and engineering intuition

are important sources of information that

employees should feel comfortable

offering without fear of retribution.

See F6.1-4

Leadership
* Broadly Applicable

A-32

Diaz

Team # CAIB # CAIB Report Recommendations andPertinent Factors BA* Diaz Summary Discussion Specific Action Category

to influence managers' decisions,

including those made about the STS-112

foam strike.

offering without fear of retribution.

F73 F6.2-7 During STS-107, Shuttle Program

Managers were concerned with the foam

strike’s possible effect on the launch

schedule.

F74 F6.3-1 The foam strike was first seen by the

Intercenter Photo Working Group on the

morning of Flight Day Two during the

standard review of launch video and highspeed photography. The strike was larger

than any seen in the past, and the group

was concerned about possible damage to

the Orbiter. No conclusive images of the

strike existed. One camera that may have

provided an additional view was out of

focus because of an improperly

maintained lens.

F75 F6.3-2 The Chair of the Intercenter Photo

Working Group asked management to

begin the process of getting outside

imagery to help in damage assessment.

This request, the first of three, began its

journey through the management

hierarchy on Flight Day Two.

Y Streamlined lines of communication and

requests need to be identified for timecritical requirements that may have

adverse effects on program success.

See F6.1-4

Leadership

F76 F6.3-3 The Intercenter Photo Working Group

distributed its first report, including a

digitized video clip and initial assessment

of the strike, on Flight Day Two. This

information was widely disseminated to

NASA and contractor engineers, Shuttle

Program managers,

and Mission Operations Directorate

personnel.

F77 F6.3-4 Initial estimates of debris size, speed, and

origin were remarkably accurate. Initial

information available to managers stated

that the debris originated in the left bipod

area of the External Tank, was quite

large, had a high velocity, and struck the

underside of the left wing near its leading

edge. The report stated that the debris

could have hit the RCC or tile.
* Broadly Applicable

A-33

Diaz

Team # CAIB # CAIB Report Recommendations andPertinent Factors BA* Diaz Summary Discussion Specific Action Category

edge. The report stated that the debris

could have hit the RCC or tile.

F78 F6.3-5 A Debris Assessment Team began

forming on Flight Day Two to analyze the

impact. Once the debris strike was

categorized as “out of family” by United

Space Alliance, contractual obligations

led to the Team being Co-Chaired by the

cognizant contractor sub-system manager

and her NASA counterpart. The team was

not designated a Tiger Team by the

Mission Evaluation Room or Mission

Management Team.

F79 F6.3-6 Though the Team was clearly reporting

its plans (and final results) through the

Mission Evaluation Room to the Mission

Management Team, no Mission manager

appeared to “own” the Team’s actions.

The Mission Management Team, through

the Mission Evaluation Room, provided

no direction for team activities, and

Shuttle managers did not formally consult

the Team’s leaders about their progress or

interim results.

Y Best business practices define individual

responsibility, accountability, and

authority including well-defined chains

of command and organized methods for

dissent.

See F6.1-4

Leadership

F80 F6.3-7 During an organizational meeting, the

Team discussed the uncertainty of the

data and the value of on-orbit imagery to

“bound” their analysis. In its first official

meeting the next day, the Team gave its

NASA Co-Chair the action to request

imagery of Columbia on-orbit.

F81 F6.3-8 The Team routed its request for imagery

through Johnson Space Center’s

Engineering Directorate rather than

through the Mission Evaluation Room to

the Mission Management Team to the

Flight Dynamics Officer, the channel

used during a mission. This routing

diluted the urgency of their request.

Managers viewed it as a non-critical

engineering desire rather than a critical

operational need.

Y Clear lines of reporting within and

across organizations need to be

identified, documented, rehearsed, and

adhered to.

See F6.1-4

Leadership
* Broadly Applicable

A-34

Diaz

Team # CAIB # CAIB Report Recommendations andPertinent Factors BA* Diaz Summary Discussion Specific Action Category

F82 F6.3-9 Team members never realized that

management’s decision against seeking

imagery was not intended as a direct or

final response to their request.

Y Feedback systems involved in channels

of decision-making need to be developed

and adhered to, so that the workforce is

aware of the status and rationale of

decisions throughout the process.

See F6.1-4

Leadership

F83 F6.3-10 The Team’s assessment of possible tile

damage was performed using an impact

simulation that was well outside

CRATER’s test database. The Boeing

analyst was inexperienced in the use of

CRATER and the interpretation of its

results. Engineers with extensive Thermal

Protection System expertise at

Huntington Beach were not actively

involved in determining if the CRATER

results were properly interpreted.

Y Same as R3.8-2 See R3.8-2

Technical

Capabilities

F84 F6.3-11 Crater initially predicted tile damage

deeper than the actual tile depth, but

engineers used their judgment to conclude

that damage would not penetrate the

densified layer of tile. Similarly, RCC

damage conclusions were based primarily

on judgment and experience rather than

analysis.

Y Personnel need to be adequately trained

in model use, limitations, and escalation

procedures when issues arise. Engineers,

when faced with results that defy

“reality checks,” should double check

the model then raise their concerns.

See R3.8-2

Technical

Capabilities

F85 F6.3-12 For a variety of reasons, including

management failures, communication

breakdowns, inadequate imagery,

inappropriate use of assessment tools, and

flawed engineering judgments, the

damage assessments contained substantial

uncertainties.

Y Many programs across NASA have

similar scopes across multiple

organizations and likely have similar

potential problems.

See F6.1-4

Leadership

F86 F6.3-13 The assumptions (and their uncertainties)

used in the analysis were never presented

or discussed in full to either the Mission

Evaluation Room or the Mission Management Team.

F87 F6.3-14 While engineers and managers knew the

foam could have struck RCC panels; the

briefings on the analysis to the Mission

Evaluation Room and Mission

Management Team did not address RCC

damage, and neither Mission Evaluation

Room nor Mission Management Team

managers asked about it.
* Broadly Applicable

A-35

Diaz

Team # CAIB # CAIB Report Recommendations andPertinent Factors BA* Diaz Summary Discussion Specific Action Category

Room nor Mission Management Team

managers asked about it.

F88 F6.3-15 There were lapses in leadership and

communication that made it difficult for

engineers to raise concerns or understand

decisions. Management failed to actively

engage in the analysis of potential

damage caused by the foam strike.

Y Subject matter experts need to be heard

and understood when problems arise that

could affect mission success.

Communications through viewgraphs

does not work and decisions need to be

documented and communicated to all

parties.

See F6.1-4

Leadership

F89 F6.3-16 Mission Management Team meetings

occurred infrequently (five times during a

16 day mission), not every day, as

specified in Shuttle Program management

rules.

Y Operations procedures and checklist

need to be verified, communicated, and

followed for all programs.

See F6.1-1

Processes &

Rules

F90 F6.3-17 Shuttle Program Managers entered the

mission with the belief, recently

reinforced by the STS-113 Flight

Readiness Review, that a foam strike is

not a safety-of-flight issue.

F91 F6.3-18 After Program managers learned about

the foam strike, their belief that it would

not be a problem was confirmed (early,

and without analysis) by a trusted expert

who was readily accessible and spoke

from “experience.” No one in

management questioned this conclusion.

Y Experience should not be used to

dismiss concerns about safety and

mission success without a logical

rationale to support the conclusion.

NASA needs to instill a practice in

which management should prove that a

problem is not a problem rather than

reversing the burden of proof.

See F6.1-4

Leadership

F92 F6.3-19 Managers asked “Who’s requesting the

photos?” instead of assessing the merits

of the request. Management seemed more

concerned about the staff following

proper channels (even while they were

themselves taking informal advice) than

they were about the analysis.

Y There are many programs in NASA that

have large organizations with potential

problems. Leaders need to develop

processes to address the merits of

problems rather than the individuals

raising the problems.

See F6.1-4

Leadership

F93 F6.3-20 No one in the operational chain of

command for STS-107 held a security

clearance that would enable them to

understand the capabilities and limitations

of National imagery resources.

Y Many programs would benefit from

Program Managers holding active

clearances. NASA should review

clearances agency-wide to determine

which are appropriate and should be

active to achieve safety and mission

success.

34) Determine if NASA needs a

central source for maintaining

security clearances.

a. Develop a list of cleared

personnel at all clearance levels,

and maintain the list at the

appropriate security level.

Correlate the organizational

chain of command for each

major program with the

clearance list.

Processes &

Rules
* Broadly Applicable

A-36

Diaz

Team # CAIB # CAIB Report Recommendations andPertinent Factors BA* Diaz Summary Discussion Specific Action Category

chain of command for each

major program with the

clearance list.

b. Review the security

requirements for each major

program, and determine if the

number of cleared personnel is

sufficient to effectively run the

program during normal and

crisis/emergency operations.

c. Submit requests for additional

cleared personnel to meet the

delta between current and

required.

Responsibility: Code X

F94 F6.3-21 Managers associated with STS-107 began

investigating the implications of the foam

strike on the launch schedule, and took

steps to expedite post-flight analysis.

F95 F6.3-22 Program managers required engineers to

prove that the debris strike created a

safety-of-flight issue: that is, engineers

had to produce evidence that the system

was unsafe rather than prove that it was

safe.

Y There are many programs in NASA that

have large hierarchical organizations.

However, problems are identified

throughout the organizations at every

level. Leaders need to develop

processes to address the merits of

problems regardless of the source within

the hierarchy.

See F6.1-4

Leadership

F96 F6.3-23 In both the Mission Evaluation Room and

Mission Management Team meetings

over the Debris Assessment Team’s

results, the focus was on the bottom line –

was there a safety-of-flight issue, or not?

There was little discussion of analysis,

assumptions, issues, or ramifications.

Y Managers need to base critical mission

decisions on facts, not intuition. Many

programs may be faced with similar

situations, in particular where analysis

teams are located at dispersed locations.

Processes need to be in place to

accommodate such circumstances.

See R6.3-1

Learning

F97 F6.3-24 Communication did not flow effectively

up to or down from Program managers.

Y Some NASA programs span multiple

Centers and geographic locations, so this

problem could be more widespread than

the Space Shuttle Program.

Communication paths should be clearly

documented.

35) Review communications policies

and reports. The review will

focus on the requirements for

formal reporting during normal

and emergency/crisis times. For

formal reporting during normal

operating tempo, the frequency

of the reports shall be

determined, and who

produces/reviews, and approves

these reports.

Communication
* Broadly Applicable

A-37

Diaz

Team # CAIB # CAIB Report Recommendations andPertinent Factors BA* Diaz Summary Discussion Specific Action Category

determined, and who

produces/reviews, and approves

these reports.

a. After review of policies, conduct

an audit of no less than three

programs to determine

compliance and methods used.

If the programs are compliant,

determine if the methods used

are adequate.

b. Rewrite the policy(s) if required.

c. Provide training and assistance.

Responsibility: Code AE

F98 F6.3-25 Three independent requests for imagery

were initiated.

F99 F6.3-26 Much of Program Managers' information

came through informal channels, which

prevented relevant opinion and analysis

from reaching decision makers.

Y Formal reporting paths and chain of

command need to be codified,

implemented, and rehearsed in all

programs, and need to accommodate

informal sources of information.

See F6.3-24

Communication

F100 F6.3-27 Program Managers did not actively

communicate with the Debris Assessment

Team. Partly as a result of this, the Team

went through institutional, not missionrelated, channels with its request for

imagery, and confusion surrounded the

origin of imagery requests and their

subsequent denial.

Y Formal reporting paths and chain of

command need to be codified,

implemented, and rehearsed in all

programs, including feedback

mechanisms.

See F6.3-24

Communication

F101 F6.3-28 Communication was stifled by the Shuttle

Program attempts to find out who had a

“mandatory requirement” for imagery.

F102 F6.3-29 Safety representatives from the

appropriate organizations attended

meetings of the Debris Assessment Team,

Mission Evaluation Room, and Mission

Management Team, but were passive, and

therefore were not a channel through

which to voice concerns or dissenting

views.

Y Rules of engagement and organizational

responsibilities should be clearly

identified across all programs.

Employees should be trained and

encouraged to raise issues proactively

when their concerns, insights, or

knowledge would impact safety and

mission success.

See F6.3-24

Communication

F103 F6.4-1 The repair option, while logistically

viable using existing materials onboard

Columbia , relied on so many

uncertainties that NASA rated this option

“high risk.”
* Broadly Applicable

A-38

Diaz

Team # CAIB # CAIB Report Recommendations andPertinent Factors BA* Diaz Summary Discussion Specific Action Category

Columbia , relied on so many

uncertainties that NASA rated this option

“high risk.”

F104 F6.4-2 If Program managers were able to

unequivocally determine before Flight

Day Seven that there was potentially

catastrophic damage to the left wing,

accelerated processing of Atlantis might

have provided a window in which

Atlantis could rendezvous with Columbia

before Columbia’s limited consumables

ran out.

F105 F7.1-1 Throughout its history, NASA has

consistently struggled to achieve viable

safety programs and adjust them to the

constraints and vagaries of changing

budgets. Yet, according to multiple high

level independent reviews, NASA's safety

system has fallen short of the mark.

Y NASA needs to audit its staffing

practices and workforce management

practices in terms of surge and

certifications. Data needs to be

provided to executive management

regarding personnel burnout, loss of

certifications, errors, etc., so that

executives can make appropriate

determinations.

See R7.5-2

Organizational

Structure

F106 F7.4-1 The Associate Administrator for Safety

and Mission Assurance is not responsible

for safety and mission assurance

execution, as intended by the Rogers

Commission, but is responsible for Safety

and Mission Assurance policy, advice,

coordination, and budgets. This view is

consistent with NASA's recent

philosophy of management at a strategic

level at NASA Headquarters but contrary

to the Rogers' Commission

recommendation.

F107 F7.4-2 Safety and Mission Assurance

organizations supporting the Shuttle

Program are largely dependent upon the

Program for funding, which hampers their

status as independent advisors.

Y Programs need to perform assessments

to identify potential conflicts of interest

that can compromise independence.

See R7.5-2

Organizational

Structure

F108 F7.4-3 Over the last two decades, little to no

progress has been made toward attaining

integrated, independent, and detailed

analyses of risk to the Space Shuttle

system.

Y NASA needs to develop a uniform

standard of risk assessment and

management and apply it to all of its

programs including missions and

infrastructure programs.

36) Review current policies and

standards for Risk Assessment to

include cost, technical, and

schedule risk considerations.

Risk

Management
* Broadly Applicable

A-39

Diaz

Team # CAIB # CAIB Report Recommendations andPertinent Factors BA* Diaz Summary Discussion Specific Action Category

system. infrastructure programs. a. After review of policies, conduct

an audit of no less than three

programs to determine

compliance and methods used. If

the programs are compliant,

determine if the methods used

are adequate.

b. Rewrite the policy(s) if required.

c. Develop a standard for Risk

Analysis.

d. Provide training and assistance.

Responsibility: Code Q

F109 F7.4-4 System safety engineering and

management is separated from

mainstream engineering, is not vigorous

enough to have an impact on system

design, and is hidden in the other safety

disciplines at NASA Headquarters.

Y An Agency-wide safety and engineering

organization that integrates system

safety engineering and management with

mainstream engineering should be

evaluated.

See R7.5-1

Organizational

Structure

F110 F7.4-5 Risk information and data from hazard

analyses are not communicated

effectively to the risk assessment and

mission assurance processes. The Board

could not find adequate application of a

process, database, or metric analysis tool

that took an integrated, systemic view of

the entire Space Shuttle system.

Y NASA needs to develop a uniform

standard of risk assessment and

management and apply it to all of its

programs including missions and

infrastructure programs.

See F7.4-3

Risk

Management

F111 F7.4-6 The Space Shuttle Systems Integration

Office handles all Shuttle systems except

the Orbiter. Therefore, it is not a true

integration office.

Y Programs need to have clear

organizational responsibilities whether

they are geographically dispersed or

managed across centers. Programs need

to assess their organizations to determine

interdependencies and collaborative

opportunities that would impact safety

and mission success.

37) Review current policies and

standards from an organizational

structure and responsibility

perspective.

a. Conduct a comprehensive

review of organizational

structures across NASA with an

emphasis on the organization’s

ability to do systems integration.

b. Rewrite the policy(s) if required.

c. Create an organization standard

and mandate for program and

integration offices.

d. Provide training and assistance.

Responsibility: Code AE

Organizational

Structure
* Broadly Applicable

A-40

Diaz

Team # CAIB # CAIB Report Recommendations andPertinent Factors BA* Diaz Summary Discussion Specific Action Category

F112 F7.4-7 When the Integration Office convenes the

Integration Control Board, the Orbiter

Office usually does not send a

representative, and its staff makes verbal

inputs only when requested.

F113 F7.4-8 The Integration office did not have

continuous responsibility to integrate

responses to bipod foam shedding from

various offices. Sometimes the Orbiter

Office had responsibility, sometimes the

External Tank Office at Marshall Space

Flight Center had responsibility, and

sometimes the bipod shedding did not

result in any designation of an In-Flight

Anomaly. Integration did not occur.

Y Programs must determine clear

organizational lines of authority,

responsibility, and accountability.

See F7.4-6

Organizational

Structure

F114 F7.4-9 NASA information databases such as The

Problem Reporting and Corrective Action

and the Web Program Compliance

Assurance and Status System are

marginally effective decision tools.

Y NASA should assess decision support

tool effectiveness for program

management, problem identification, and

problem resolution.

38) Review current policies and

standards for decision support

tools.

a. Conduct a comprehensive

review of all NASA decision

support tools, and compile a

directory.

b. Rewrite the policy(s) if required.

c. Create a common standard and

mandate for decision support

systems across NASA.

d. Provide training and

development assistance on

decision support tools.

See F7.4-10/11

Responsibility: Code AE

Learning

F115 F7.4-10 Senior Safety, Reliability & Quality

Assurance and element managers do not

use the Lessons Learned Information

System when making decisions. NASA

subsequently does not have a constructive

program to use past lessons to educate

engineers, managers, astronauts, or safety

personnel.

Y Training programs that leverage case

studies and lessons learned capabilities

are characteristic of other Federal and

commercial organizations and should be

adopted by NASA and implemented

across the entire Agency as appropriate.

See F7.4-11

Learning

F116 F7.4-11 The Space Shuttle Program has a wealth

of data tucked away in multiple databases

without a convenient way to integrate and

use the data for management,

engineering, or safety decisions.

Y NASA should address database

commonality and real-time access just as

it did for the Integrated Financial

Management Program (IFMP).

39) Review current policies and

standards for databases and

knowledge sharing.

Learning
* Broadly Applicable

A-41

Diaz

Team # CAIB # CAIB Report Recommendations andPertinent Factors BA* Diaz Summary Discussion Specific Action Category

without a convenient way to integrate and

use the data for management,

engineering, or safety decisions.

it did for the Integrated Financial

Management Program (IFMP).

knowledge sharing.

a. Conduct a comprehensive

review of all NASA databases,

and compile a directory.

b. Rewrite the policy(s) if required.

c. Create a common standard and

mandate for database real-time

access across NASA.

d. Provide training and

development assistance on the

database standard and associated

real-time access process that is

developed.

Responsibility: Code AE

F117 F7.4-12 The dependence of Safety, Reliability &

Quality Assurance personnel on Shuttle

Program support limits their ability to

oversee operations and communicate

potential problems throughout the

organization.

Y Programs should identify internal

conflicts of interest and address means

for mitigation.

See R7.5-2

Organizational

Structure

F118 F7.4-13 There are conflicting roles,

responsibilities, and guidance in the

Space Shuttle safety programs. The

Safety & Mission Assurance Pre-Launch

Assessment Review process is not

recognized by the Space Shuttle Program

as a requirement that must be followed

(NSTS 22778). Failure to consistently

apply the Pre-Launch Assessment Review

as a requirements document creates

confusion about roles and responsibilities

in the NASA safety organization.

Y Programs should perform periodic audits

to identify internal conflicts of interest;

process conflicts; and other program

operational inconsistencies, roles, and

responsibilities and address means for

mitigation.

See R7.5-2

Organizational

Structure

F119 F10.1-1 The Columbia accident demonstrated that

Orbiter breakup during re-entry has the

potential to cause casualties among the

general public.

Y Same as O10.1-1

See O10.1-1 Risk

Management

F120 F10.1-2 Given the best information available to

date, a formal risk analysis sponsored by

the Board found that the lack of generalpublic casualties from Columbia’s breakup was the expected outcome.

Y Programs should know all results of risk

analyses, regardless of the anticipated

outcome, and factor those considerations

into safety and mission success planning

and contingency management activities.

See O10.1-1

Risk

Management
* Broadly Applicable

A-42

Diaz

Team # CAIB # CAIB Report Recommendations andPertinent Factors BA* Diaz Summary Discussion Specific Action Category

F121 F10.1-3 The history of U.S. space flight has a

flawless public safety record. Since the

1950s, hundreds of space flights have

occurred without a single public injury.

Y Safety should be based on logical risk

assessments. Small sample statistics

provide for an uninformed development

of intuition.

See O10.1-1

Risk

Management

F122 F10.1-4 The FAA and U.S. space launch ranges

have safety standards designed to ensure

that the general public is exposed to less

than a one-in-a-million chance of serious

injury from the operation of space launch

vehicles and unmanned aircraft.

Y NASA policies recognize requirements

for public safety. Those policies should

be reviewed and the models used should

be continually updated and assessed with

respect to value in supporting timely

decision making.

See O10.1-1

Risk

Management

F123 F10.1-5 NASA did not demonstrably follow

public risk acceptability standards during

past Orbiter re-entries. NASA efforts are

underway to define a national policy for

the protection of public safety during all

operations involving space launch

vehicles.

Y Same as F10.1-4 See O10.1-1

Risk

Management

F124 F10.3-1 The engineering drawing system contains

outdated information and is paper-based

rather than computer-aided.

Y Accurate and comprehensive

engineering drawings should be

maintained for all programs. These

drawings must be computer-aided.

See R10.3-1

Technical

Capabilities

F125 F10.3-2 The current drawing system cannot

quickly portray Shuttle sub-systems for

on-orbit troubleshooting.

F126 F10.3-3 NASA normally uses closeout

photographs but lacks a clear system to

define which critical sub-systems should

have such photographs. The current

system does not allow the immediate

retrieval of closeout photos.

Y Standards for taking, organizing,

preserving, handling, and managing

closeout photographs should be

uniformly applied across all of NASA’s

programs.

See R10.3-1

Technical

Capabilities

F127 F10.4-1 Shuttle System industrial safety programs

are in good health.

Y The state of health of all NASA

industrial safety programs should be

reviewed.

40) Review current policies and

regulations on industrial safety

programs.

a. After review of policies and

regulations, conduct an audit of

no less than three programs to

determine compliance.

b. Compile the results; develop a

recommendation.

c. If required, rewrite the policies

to comply with regulations.

Risk

Management
* Broadly Applicable

A-43

Diaz

Team # CAIB # CAIB Report Recommendations andPertinent Factors BA

* Diaz Summary Discussion Specific Action Category

Responsibility: Code Q

F128 F10.4-2 The Quality Planning Requirements

Document, which defines inspection

conditions, was well formulated.

However, there is no requirement that it

be routinely reviewed.

F129 F10.4-3 Kennedy Space Center’s current

government mandatory inspection process

is both inadequate and difficult to expand,

which inhibits the ability of Quality

Assurance to process improvement

initiatives.

F130 F10.4-4 Kennedy’s quality assurance system

encourages inspectors to allow incorrect

work to be corrected without being

labeled “rejected.” These opportunities

hide “rejections,” making it impossible to

determine how often and on what items

frequent rejections and errors occur.

F131 F10.8-1 The present design and fabrication of the

lower carrier panel attachments are

inadequate. The bolts can readily pull

through the relatively large holes in the

box beams.

F132 F10.8-2 The current design of the box beam in the

lower carrier panel assembly exposes the

attachment bolts to a rapid exchange of

air along the wing, which enables the

failure of numerous bolts.

F133 F10.8-3 Primers and sealants such as Room

Temperature Vulcanizing 560 and

Koropon may accelerate corrosion,

particularly in tight crevices.

F134 F10.8-4 The negligible compressive stresses that

normally occur in A-286 bolts help

protect against failure.

F135 F10.9-1 The Hold-Down Post External Tank Vent

Arm System is a Criticality 1R

(redundant) system. Before the anomaly

on STS-112, and despite the highcriticality factor, the original cabling for

this system was used repeatedly until it

was visibly damaged. Replacing these

cables after every flight and removing the

Kapton will prevent bending and

manipulation damage.
* Broadly Applicable

A-44

Diaz

Team # CAIB # CAIB Report Recommendations andPertinent Factors BA

* Diaz Summary Discussion Specific Action Category

was visibly damaged. Replacing these

cables after every flight and removing the

Kapton will prevent bending and

manipulation damage.

F136 F10.9-2 NASA is unclear about the potential for

damage if the system malfunctions, or

even if one nut fails to split. Several

program managers were asked: What if

the A system fails, and a B-system

initiator fails simultaneously? The

consensus was that the system would

continue to burn on the pad or that the

Solid Rocket Booster would rip free of

the pad, causing potentially catastrophic

damage to the Solid Rocket Booster skirt

and nozzle maneuvering mechanism.

However, they agree that the probability

of this is extremely low.

F137 F10.9-3With the exception of STS-112’s

anomaly, numerous bolt hang-ups, and

occasional Master Events Controller

failures, these systems have a good

record. In the early design stages, riskmitigating options were considered,

including strapping with either a wire that

crosses over the nut from the A to B side,

or with a toggle circuit that sends a signal

to the opposite side when either initiator

fires. Both options would eliminate the

potential of a catastrophic dual failure.

However, they could also create new

failure potentials that may not reduce

overall system risk. Today’s test and

troubleshooting technology may have

improved the ability to test circuits and

potentially prevent intermittent failures,

but it is not clear if NASA has explored

these options.
APPENDIX B ACRONYMS

CAD Computer-Aided Design Computer-Aided Design

CAIB Columbia Accident Investigation Board Columbia Accident Investigation Board 

CARD Cost Analysis Resource Document Cost Analysis Resource Document

CFT Continuing Flight Team Continuing Flight Team 

CMM Capability Maturity Model

CRM Crew Resource Management

DOD Department of Defense

DOE Department of Energy Department of Energy

ET External Tank External Tank

FAA Federal Aviation Administration Federal Aviation Administration

HR Human Resources

IFMP Integrated Financial Management Program

ISO International Standard Organization International Standard Organization

ISS International Space Station

ITEA Independent Technical Engineering Authority Independent Technical Engineering Authority

LCC Life Cycle Cost 

MOA Memorandum of Agreement Memorandum of Agreement 

NASA National Aeronautics and Space Administration National Aeronautics and Space Administration

NESC NASA Engineering and Safety Center NASA Engineering and Safety Center 

NGA National Geospatial-Intelligence Agency National Geospatial-Intelligence Agency

NIMA National Imagery & Mapping Agency National Imagery & Mapping Agency

NPD NASA Policy Directive NASA Policy Directive

NSTS National Space Transportation System National Space Transportation System

R&D Research and Development

RCC Reinforced Carbon-Carbon

R-O-F Recommendations, Observations, and Findings 

RTF Return to Flight

SEI Software Engineering Institute

S&MA Safety and Mission Assurance Safety and Mission Assurance 

SR&QA Safety, Reliability, & Quality Assurance Safety, Reliability, & Quality Assurance

TRL Technology Readiness Level Technology Readiness Level

USA United Space Alliance United Space Alliance

Acronym Key

B - 1