TO THE MOON...

AEROSPACE SAFETY 

ADVISORY PANEL

Annual Report 

for 2021
NASA AEROSPACE SAFETY ADVISORY PANEL

National Aeronautics and Space Administration

Washington, DC 20546

Dr. Patricia Sanders, Chair

January 1, 2022

The Honorable Bill Nelson

Administrator

National Aeronautics and Space Administration

Washington, DC 20546

Dear Sen. Nelson:

Pursuant to Section 106(b) of the National Aeronautics and Space Administration Authorization Act 2005 (P.L. 

109-155), the Aerospace Safety Advisory Panel (ASAP) is pleased to submit the ASAP Annual Report for 2021 

to the U.S. Congress and to the Administrator of the National Aeronautics and Space Administration (NASA). 

The Report is based on the Panel’s 2021 fact-finding and quarterly public meetings; direct observations of NASA 

operations and decision-making; discussions with NASA management, employees, and contractors; and the Panel 

members’ past experiences. 

Since its creation, NASA has been responsible for some truly remarkable accomplishments in science, engineering, 

and exploration. Sixty years of NASA’s efforts and U.S. government investments have been instrumental in the 

establishment of the foundational knowledge leveraged by the world. But past accomplishments do not guarantee 

future success, and the space sector, both domestically and internationally, is rapidly transforming. More nations 

are engaged in space activities than at any point in history, and private industry is recognizing the economic value 

of the space domain.

The rapid changes occurring in space technology, investment, and operations define an inflection point for the 

space sector. As NASA looks to the future and moves to expand human knowledge and operational capabilities 

beyond LEO, it must recognize and adapt to the new environment and decide strategically how to forge humanity’s 

path outward while managing the risks in an appropriate manner. 

The Panel believes that how NASA manages human space flight programs can have a significant impact on the 

risks associated with those programs. We believe that NASA’s vision for the future, and a clear definition of how 

it will evaluate and make decisions related to risk, are extremely important factors in ensuring human space flight 

safety. As a result, the primary focus of this report is the urgent need for NASA to strategically define its future role 

and articulate a vision and a set of guiding principles to direct its efforts. We are proposing three formal recommendations to that end.

I submit the ASAP Annual Report for 2021 with respect and appreciation. 

Sincerely,

Dr. Patricia Sanders

Chair, Aerospace Safety Advisory Panel

Enclosure
NASA AEROSPACE SAFETY ADVISORY PANEL

National Aeronautics and Space Administration

Washington, DC 20546

Dr. Patricia Sanders, Chair

January 1, 2022

The Honorable Kamala D. Harris

President of the Senate

Washington, DC 20510

Dear Madam President:

Pursuant to Section 106(b) of the National Aeronautics and Space Administration Authorization Act 2005 (P.L. 

109-155), the Aerospace Safety Advisory Panel (ASAP) is pleased to submit the ASAP Annual Report for 2021 

to the U.S. Congress and to the Administrator of the National Aeronautics and Space Administration (NASA). 

The Report is based on the Panel’s 2021 fact-finding and quarterly public meetings; direct observations of NASA 

operations and decision-making; discussions with NASA management, employees, and contractors; and the Panel 

members’ past experiences. 

Since its creation, NASA has been responsible for some truly remarkable accomplishments in science, engineering, 

and exploration. Sixty years of NASA’s efforts and U.S. government investments have been instrumental in the 

establishment of the foundational knowledge leveraged by the world. But past accomplishments do not guarantee 

future success, and the space sector, both domestically and internationally, is rapidly transforming. More nations 

are engaged in space activities than at any point in history, and private industry is recognizing the economic value 

of the space domain.

The rapid changes occurring in space technology, investment, and operations define an inflection point for the 

space sector. As NASA looks to the future and moves to expand human knowledge and operational capabilities 

beyond LEO, it must recognize and adapt to the new environment and decide strategically how to forge humanity’s 

path outward while managing the risks in an appropriate manner. 

The Panel believes that how NASA manages human space flight programs can have a significant impact on the 

risks associated with those programs. We believe that NASA’s vision for the future, and a clear definition of how 

it will evaluate and make decisions related to risk, are extremely important factors in ensuring human space flight 

safety. As a result, the primary focus of this report is the urgent need for NASA to strategically define its future role 

and articulate a vision and a set of guiding principles to direct its efforts. We are proposing three formal recommendations to that end.

I submit the ASAP Annual Report for 2021 with respect and appreciation. 

Sincerely,

Dr. Patricia Sanders

Chair, Aerospace Safety Advisory Panel

Enclosure
NASA AEROSPACE SAFETY ADVISORY PANEL

National Aeronautics and Space Administration

Washington, DC 20546

Dr. Patricia Sanders, Chair

January 1, 2022

The Honorable Nancy Pelosi

Speaker of the House of Representatives

Washington, DC 20510

Dear Madam Speaker:

Pursuant to Section 106(b) of the National Aeronautics and Space Administration Authorization Act 2005 (P.L. 

109-155), the Aerospace Safety Advisory Panel (ASAP) is pleased to submit the ASAP Annual Report for 2021 

to the U.S. Congress and to the Administrator of the National Aeronautics and Space Administration (NASA). 

The Report is based on the Panel’s 2021 fact-finding and quarterly public meetings; direct observations of NASA 

operations and decision-making; discussions with NASA management, employees, and contractors; and the Panel 

members’ past experiences. 

Since its creation, NASA has been responsible for some truly remarkable accomplishments in science, engineering, 

and exploration. Sixty years of NASA’s efforts and U.S. government investments have been instrumental in the 

establishment of the foundational knowledge leveraged by the world. But past accomplishments do not guarantee 

future success, and the space sector, both domestically and internationally, is rapidly transforming. More nations 

are engaged in space activities than at any point in history, and private industry is recognizing the economic value 

of the space domain.

The rapid changes occurring in space technology, investment, and operations define an inflection point for the 

space sector. As NASA looks to the future and moves to expand human knowledge and operational capabilities 

beyond LEO, it must recognize and adapt to the new environment and decide strategically how to forge humanity’s 

path outward while managing the risks in an appropriate manner. 

The Panel believes that how NASA manages human space flight programs can have a significant impact on the 

risks associated with those programs. We believe that NASA’s vision for the future, and a clear definition of how 

it will evaluate and make decisions related to risk, are extremely important factors in ensuring human space flight 

safety. As a result, the primary focus of this report is the urgent need for NASA to strategically define its future role 

and articulate a vision and a set of guiding principles to direct its efforts. We are proposing three formal recommendations to that end.

I submit the ASAP Annual Report for 2021 with respect and appreciation. 

Sincerely,

Dr. Patricia Sanders

Chair, Aerospace Safety Advisory Panel

Enclosure
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Contents

 Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

I. Introduction and Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

II. Problem/Opportunity Statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

III. Strategic Vision and Guiding Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1

IV. Agency Governance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1

V. Program Management Across the NASA Enterprise . . . . . . . . . . . . . . . . . . . . . . 2

VI. Congressional Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

VII. Forward Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

VIII. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Appendix A Summary and Status of Aerospace Safety Advisory Panel (ASAP) 

Open Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Appendix B Closure Rationale for Recommendations Closed in 2021 . . . . . . . . 4

Appendix C ASAP Members and Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  4

The ASAP Charter and Quarterly Meeting Minutes can be found at https://oiir.hq.nasa.gov/asap/
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Preface

The Aerospace Safety Advisory Panel (ASAP) was established by Congress in 1968 to provide advice 

and make recommendations to the NASA Administrator on safety matters. The Panel holds quarterly 

fact-finding and public meetings and makes “insight” visits to NASA Field Centers or other related 

sites. It reviews safety studies and operations plans and advises the NASA Administrator and Congress 

on hazards related to proposed or existing facilities and operations, safety standards and reporting, 

safety, and mission assurance aspects regarding ongoing or proposed programs, and NASA management and culture issues related to safety. Although the Panel may perform other duties and tasks as 

requested by either the NASA Administrator or Congress, the ASAP members normally do not engage 

in specialized studies or detailed technical analyses. 

This report highlights the issues and concerns the Panel identified or raised during its activities 

over the past year. The full text of the recommendations submitted to the Administrator during 2021 

is included as Appendix A, along with the Panel’s open recommendations from prior years. Rationale 

for recommendations closed in 2021 is included as Appendix B. The Panel’s issues, concerns, and recommendations are based upon the ASAP fact-finding and quarterly public meetings; insight visits and 

meetings; direct observations of NASA operations and decision-making; discussions with NASA management, employees, and contractors; and the Panel members’ expertise.
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I. Introduction and Overview

Throughout 2021, in a series of insight and fact-finding discussions and our quarterly meetings—all 

conducted virtually in deference to the ongoing pandemic impact—we both explored the status of 

NASA’s ongoing program of work and focused on the longer term, strategic posture of the Agency to 

address risk management. As a result, this report continues our focus on strategic issues and their bearing on current development, exploration, and operational matters. 

This report discusses why the ASAP continues to recommend that NASA provide answers to the 

strategic questions we posed in our 2020 Annual Report, and based on that strategic self-inspection, 

address three specific recommendations that we make in this year’s Report.

We also reiterate our past advice to Congress with respect to the actions we believe must be taken 

for the safety of space operations in the evolving environment. 

II. Problem/Opportunity Statement

Since its creation on October 1, 1958, NASA has been responsible for some truly remarkable accomplishments in science, engineering, and exploration. As an organization, it is admired around the 

world, and it regularly wins awards such as “The Best Place to Work in the Federal Government.” 

However, past achievement does not guarantee future success. NASA has also had its share of failures, 

some of which have come with costly lessons that must inform future choices. For NASA to continue 

its trajectory of success in the decades ahead, it must proactively plan for and manage its work in the 

presence of the numerous challenges, constraints, and risks inherent in the changing environment of 

the aerospace community.

As the ASAP discussed in last year’s annual report, how NASA conducts its human space flight 

programs has evolved. From its founding, and for much of its history, NASA took responsibility for 

defining, directing, and executing almost all of its major programs. Later, NASA made conscious decisions to share responsibility for managing significant portions of certain programs with industry. More 

recently, several of NASA’s key programs have been almost entirely managed by industry. This evolution in who has what responsibility occurred in response to several drivers, including:

f The belief that it may allow for lower program costs.

f The potential to significantly shorten development schedules.

f A deliberate strategy to turn some activities over to industry to enable NASA to focus its efforts 

and its budgets on more challenging tasks, including exploration beyond low-Earth orbit (LEO).

The rebalancing of roles and responsibilities between NASA and industry has generally succeeded, 

but this trend has changed how NASA executes its mission. Specifically:
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f For a significant portion of its program portfolio, NASA is no longer responsible for deciding 

how systems are designed, developed, and tested.

f Increasingly, NASA is becoming a customer rather than an owner/operator.

f Rather than directing all human spaceflight programs, NASA is more frequently engaging 

with—and relying on—industry and international partners.

If these trends continue, which seems likely, the Panel believes it is crucial for NASA to strategically evaluate the path ahead and determine the future shape of the organization. Once the Agency 

has clarified a vision and strategy, it should then make the decisions, and take the necessary actions, to 

enable it to accomplish the required transformation. And, regardless of the vision NASA conceives for 

its future, the Agency must also operate as efficiently as possible to manage fixed costs and to maximize 

the budget available for mission-related work.

As part of this report, the Panel has identified a series of issues that NASA will need to address 

with respect to its plans and aspirations for the future; how it intends to interact with both commercial 

and international partners; its risk management approach; and its changing workforce and infrastructure needs. We offer three specific top-level recommendations as improvement opportunities related 

to NASA’s Strategic Vision and Guiding Principles, Agency Governance, and Program Management.

A. Inflection Point—Why is Now the Right Time to Address These Issues? 

The rapid changes occurring in space technology, investment, and operations—and the growth of a 

commercial sector interested in pursuits beyond those driven by government requirements—define an 

inflection point for the space sector. In the past, space activity was primarily sourced directly by government-defined missions. In the future, the government will be only one of many customers, and 

industry will develop and bring to bear an increasingly broad and technologically sophisticated set 

of capabilities. As this transformation progresses, it is hard to predict the array of human space flight 

activities that might be under way 20 years from now. In two decades, LEO might be crowded with 

multiple commercial space stations, a propellant depot or two, and numerous solar power satellites, 

with a fleet of space tugs carrying crew and cargo back and forth through cis-lunar space. The south 

pole of the Moon could be the site of a major scientific research base, complete with habitats and mining sites. Other experiment stations might operate simultaneously in multiple locations. It is certainly 

possible that before two decades pass, astronauts will have landed on Mars. 

Funding such endeavors will obviously take considerable resources. However, history suggests (as 

shown in Figure 1) it is unlikely NASA’s budget will ever again exceed 1% of the federal budget, as it 

did during the lead-up to the Apollo Program. Consequently, it will not be possible for NASA to single-handedly carry out all of the missions now envisioned. Considering its ambitious goals and constrained budget, for NASA—and hence the United States—to continue to play a strategic leadership 

role in space, the Agency must transform. While private industry efforts are an ever more important 

factor in the U.S. government’s future endeavors, the commercial sector alone has not, and will not, be 
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the vehicle that drives national goals. Consequently, the Agency will need to operate differently—from 

strategic planning and how it approaches program management, to workforce development, facility 

maintenance, acquisition strategies, contract types, and partnerships. 

Calendar Year

Percentage of Federal Budget

4.0

3.0

2.0

1.0

0.0

1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015

FIGURE 1. Historical NASA Budgets as a Percent of the Federal Budget

Drivers for the need to transform include: 

f Missions to the Moon and Mars are significantly more complex than the objectives of previous 

programs, with multiple launches and a variety of vehicles required for each expedition.

f The increase in mission complexity requires considerably more integration “touchpoints” 

between supporting programs, leading to increased oversight and program expenses.

f Sustained lunar and Martian missions will involve significantly greater risk than NASA’s previous human space flight experiences in the LEO regime. The global space community still has 

much to learn about supporting humans on other planetary bodies for long durations.

f The pace of technological change will almost certainly continue to increase, requiring designs 

and systems that are flexible enough to integrate advantageous advancements. 

f The aerospace industry has become much more diverse and innovative, and companies are willing and able to make major contributions as contractors, service providers, or partners.

f Having benefitted from a positive experience with the International Space Station (ISS), the 

international community has made it clear that it would like to work with NASA on future 

exploration programs.
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B. Is This Really a Safety Issue?

As described in the ASAP charter, the Panel is tasked to provide advice and make recommendations on 

matters related to safety. Changes in how NASA manages human space flight programs have a significant impact on the risks associated with those programs. As one example, the overall strategy NASA 

decides to use for a particular program—whether to “make, manage, or buy”—has major implications 

for the kind of expertise and experience the Agency’s workforce will need to successfully execute the 

program and manage the associated risks. 

The Panel believes that NASA’s vision for the future, and a clear definition of how it will evaluate and make decisions related to risk (in addition to how it will manage and execute programs), are 

extremely important factors in ensuring human space flight safety. As a result, the primary focus of 

this report is the urgent need for NASA to strategically define its future role and articulate a vision and 

a set of guiding principles to direct its efforts.

As NASA continues to evolve and define its future role, it is important for the Agency and its 

stakeholders—Congress, other Executive branch entities, the private sector, and the taxpayers—to 

understand the context in which NASA has successfully operated for the past 50 years. By having a 

clear understanding of what drove, and continues to drive, Agency culture and thinking, NASA and 

its stakeholder community can work intentionally to chart a meaningful and impactful role for the 

Agency in the future. Ignoring the external forces and environment in which the Agency must function will place NASA in a tenuous position going forward, which in turn will impact how safely and 

successfully it will be able to carry out U.S. government missions in space. 

C. Challenges of NASA’s Internal and External Environments

NASA’s structure, organizational dynamics, and workforce culture are grounded in how the Agency 

was formed and shaped by the dynamics of its stakeholders. The Agency was established before society 

had any foundational engineering and operational experience related to sending humans to live and 

work in space. Consequently, NASA had to create the workforce and knowledge necessary to engage 

in human space flight safely and successfully. As the complex undertaking of sending humans to the 

Moon evolved during the 1960s, NASA centers each invested in specific technical or operational 

expertise—a defining feature of the very same centers that is still true today. As NASA grew and established new programs, the work divided across the different centers shifted and evolved but was still 

fundamentally driven by the early distribution of technical expertise. At times, however, a competitive dynamic emerged between NASA centers, particularly those that primarily support human space 

flight, often energized by local stakeholders. 

Over the decades, at various times with varying amounts of success, NASA leadership has sought 

to create an Agency-wide identity and foster greater coordination. There remains, however, a very 

strong and separate culture at each NASA Center. This drives the Centers to prioritize their own 

goals rather than those of the overall Agency, and it creates pressure against the implementation of a 
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strategic approach that aligns the whole organization to a common set of goals. Importantly, moreover, the resource flow remains center-focused rather than optimized around integrated outcomes.

Today, more than six decades after its founding, the Agency is at an inflection point. The space 

industry has matured and has developed a breadth and depth of capabilities available at lower costs 

than NASA would incur to develop or maintain those capabilities itself. Because industry capabilities 

are so enhanced, NASA is challenged to reduce its costs for those programs it chooses to develop internally. But the Agency’s structure, culture, and stakeholder dynamics have created significant drag on 

its ability to achieve this goal. 

In this context, NASA is slowly adapting its approaches to industry management. NASA’s efforts 

and learning have progressed at a tactical level through case-by-case execution, however. A broader, 

more comprehensive Agency-wide evolutionary approach is required. NASA must grow more efficient 

and flexible—not only to meet stakeholder expectations, but also to operate in an environment where 

the private sector is emerging as a major independent contributor to the execution of NASA missions—while still continuing to manage risk as effectively as it has in the past. 

In addition, as NASA adapts internally to remain successful in its changing external environment, 

the expectations of its stakeholder communities—specifically Congress and the Executive Branch—

must also adapt. The Panel has stressed the importance of constancy of purpose and its role in the 

ability of the Agency to manage risk intelligently and proactively. Not only do consistency and clarity of objectives help the Agency plan more efficiently, but they also send a clear message to the workforce about the Agency’s direction, providing focus and background for decision-making at all levels. 

Constant and abrupt changes in direction create inefficiencies in planning and execution that create confusion and uncertainty in the workforce and dilute the focus in decision-making, all of which 

increase cost and risk. Importantly, over the past two Administrations, the Moon has remained steady 

as a primary mission. Prior transitions were not as smooth, however. 

Disruptive changes in direction not only decrease the ability of the Agency to operate efficiently, 

but they also shape internal NASA culture. To illustrate (see Figure 2), as the Space Shuttle program 

was ending, the Constellation program gave the Agency a clear mandate to return to the Moon. When 

the Constellation program was cancelled, after an Administration-level review of program performance, the Agency was redirected to an asteroid landing mission, an objective that made less technical 

sense for a long-term development of interplanetary capability. When the asteroid objective lost traction within a few years, it created a ripple of uncertainty and the loss of a strong mission focus in the 

workforce that echoes to this day. The abruptness of these changes in direction for NASA’s primary 

touchstone program caught the whole community—but especially the NASA workforce—by surprise. 

Confusing communication about the Administration’s rationale and the lack of supporting technical 

data for the asteroid mission, especially for an agency that bases its very successes on a strong technical 

culture, created a lack of trust. And, to many in the NASA workforce, the Moon then became a forbidden subject of consideration, even though the Moon was rightly perceived as the next technically 

advantaged step and logical risk management choice in human exploration. 
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1981–1989

Ronald Reagan

1989–1993

George H.W. 

Bush

1993–2001

Bill Clinton

1989–1993

Space Exploration 

Initiative

Space Shuttle Program Operations SSP Closeout

Closeout

NASA Program (X-30) Design

Space Station Freedom Program Design

VentureStar Program

ISS Program Design

ACRV Design

Constellation Program Design

Exploration Systems Development Program Design

Asteroid Redirect

Gateway Design

HLS Design

Commercial Crew Program (CCP) Design

CCP Ops

Shuttle–Mir Program

Orbital Space Plane Design

Mission Design

Design

International Space Station Program Operations

Oct 11, 2010

Constellation Canceled; 

SLS, MPCF, GSDO Initated

Dec. 2005

NASA Authorization Act, 

Constellation Standup

2004–2009

Vision for Space 

Exploration/ 

Constellation

2018–present

Return to Moon/ 

Artemis

2001–2009

George W. Bush

2009–2017

Barack Obama

2017–2021

Donald Trump

2021–

Joe 

Biden

1990 19901985 19851995 19952005 20052015 20152000 20002010 20102020 2020

Executive Branch NASA Human Spaceflight Programs Congress

Jun. 1993

Space Station 

Survives by 1 Vote

FIGURE 2. Historical Changes in Program Direction

The cultural dynamics prompted by the instability of purpose and the disconnect between purpose 

and technical rationale now appear to be normalized into the organizational culture. NASA leaders, 

unable to discuss a comprehensive lunar program, were driven to create tools and capabilities outside 

the traditional program context the Agency had always used to manage complex integrated capabilities 

throughout its history. Consequently, the Exploration Ground Systems (EGS), Orion, and the Space 

Launch System (SLS) were established as three individual programs, each with their own processes, 

structures, and management approaches, rather than being integrated as what previously would have 

been a single program. These three individual programs were then distributed across the three major 

NASA human space flight centers to make the resource allocation equitable and to satisfy stakeholder 

requirements. 

Unfortunately, this approach left a critical gap in the system-of-systems integration process that is 

usually filled by having a single overarching program umbrella with requisite program authorities and 

integration responsibilities. In the absence of a formal program umbrella, NASA Headquarters created 

a bottom-up integration effort, which required the individual programs to negotiate among themselves. 
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This is a difficult proposition for managing design and operational changes that allocate risk to different elements, which then impacts individual program cost and schedule. The Panel notes that such 

an approach often prioritizes consensus, rather than decision-making by an accountable leader, which 

makes resolution of tough integration, resource, and risk management issues even more challenging. 

In adopting this disaggregated, decentralized program structure between SLS, EGS, and Orion, 

with the view that it is a manageable alternative to the familiar and effective program framework 

that served it well for the Apollo, STS, and ISS programs, NASA has seemed to overlook the negative impacts to cohesive integrated risk management. In essence, it appears that the cancellation of 

the Constellation program has led to a cautious stance among NASA leaders driven by the assumption that having an Apollo-like program now is a problematic political optic, and like Constellation, a 

possible target for cancellation by a future Administration. In effect, NASA has accepted the disaggregated program structure as normal, and is now propagating this structure as a preferred business and 

risk management model, even though it is essentially an untried approach for an integrated systems 

engineering effort of this magnitude and complexity. 

Thus, behavior that was instantiated as a coping mechanism for unstable political guidance has 

become institutionalized—as has the embedded uncertainty in risk management. Furthermore, the 

Agency is attempting to manage the risk in the structure it has adopted without deliberately assessing 

why the structure is at least equivalent to, if not an improvement to, a more familiar structure, and 

whether it should be advanced as a wholly new program approach.

Beyond this, pressures from myriad stakeholders across the Executive and Legislative branches of 

government mean NASA faces other dynamics that impact its ability to execute. These stakeholders, 

from the Office of Management and Budget, to separate Congressional delegations/offices, have various agendas and can generate competing and occasionally contradictory directives for the Agency. 

Each stakeholder’s priorities drive particular tasks and workflows that undercut holistic optimization 

at the Agency level. This strains NASA’s ability to manage its own internal costs, especially those associated with infrastructure and labor. While understandable that individual stakeholders emphasize 

their own interests and concerns, the simultaneous insistence across all stakeholders that NASA execute an increasingly large number of very complex missions creates an environment for increased risk 

and unintended impacts on safety. With constrained resources come limitations on the deep technical examination necessary to fully understand integrated mission risk. It is unrealistic to expect NASA 

to operate efficiently when pulled in so many different directions. Therefore, it is hard for the nation, 

and thus the Agency, to have a coherent conversation about national objectives, let alone formulate an 

approach on how to meet those objectives. 

The Constellation program provides another example of this dynamic. One of the major factors cited for the program’s cancellation was that it was unacceptably over budget. One reason the 

Constellation budget became inflated was because NASA’s fixed costs, previously absorbed by the 

Space Shuttle program, were planned to be transferred to the Constellation program—along with 

the obsolete, and in some cases, unnecessary infrastructure that drove costs higher—simply because 
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Constellation was the next long-term NASA human space flight program. That extra burden imposed 

on the Constellation program strained the budget—a budget originally allocated for a developmental 

program, not designed for the additional labor and facilities costs it inherited. Exacerbating this problem was the fact that as the Shuttle program was being retired, the Agency was directed to retain all 

civil servants. 

And finally, the national budget formulation process influences NASA’s ability to operate more 

efficiently, and directly impacts risk and safety, just as it does other agencies. Like other agencies, 

NASA receives its budget allocation annually. For the last decade, that process has been routinely 

delayed, requiring the Agency to work in a constant environment of budget uncertainty. Although it 

is well understood that the budget profile for a complex engineering system requires significantly more 

up-front investment during the design and development phase, NASA must manage its programs with 

essentially flat line spending profiles from year-to-year (see Figure 3). In an uncertain and constrained 

NASA Continuing Resolution History

Fiscal Year (FY) 2008–2022

FY 

2008

FY 

2009

FY 

2010

FY 

2011

FY 

2012

FY 

2013

FY 

2014

FY 

2015

FY 

2016

FY 

2017

FY 

2018

FY 

2019

FY 

2020

FY 

2021

FY 

2022

CR-1 PL 

110-92

PL 

110-329

PL 

111-68

PL 

111-242

PL 

112-33

PL 

112-75

PL 

113-44

PL 

113-164

PL 

114-53

PL 

114-223

PL 

115-56

PL 

115-245

PL 

116-59

PL 

116-159

PL 

117-43

CR-2 PL 

110-116

PL 

111-6

PL 

111-88

PL 

111-290

PL 

112-36

PL 

113-67

PL 

113-202

PL 

114-96

PL 

114-254

PL 

115-90

* PL 

115-298

PL 

116-69

PL 

116-215

PL 

117-70

CR-3 PL 

110-137

PL 

111-317

PL 

112-55

PL 

113-73

PL 

113-203

PL 

114-100

PL 

115-30

PL 

115-96

PL 

116-5

PL 

116-225

CR-4 PL 

110-149

PL 

111-322

PL 

112-67

PL 

115-120

PL 

116-226

CR-5 PL 

112-4

PL 

112-68

PL 

115-123

PL 

116-246

CR-6 PL 

112-6

CR-7 PL 

112-8

CR-8 PL 

112-10

Final 

Approp.

PL 

110-161

PL 

111-8

PL 

111-117

PL 

112-10

PL 

112-55

PL 

113-6

PL 

113-76

PL 

113-235

PL 

114-113 

PL 

115-31

PL 

115-141

PL 

116-6

PL 

116-93

PL 

116-260

Omnibus ● ● ● ● ● ● ● ● ● ● ●

Minibus ▲ ▲ ▲

Data 

Enacted

12/26

2007

03/11

2009

12/16

2009

04/15

2011

11/18

2011

03/26

2013

01/17

2014

12/16

2014

12/18

2015

05/05

2017

3/23

2018

2/15

2019

12/20

2019

12/27

2020

Months 

Under CR 3 6 3 12 2 6 4 3 3 7 6 5 2 3 TBD

* NOTE: Lapse in appropriations for all Government agencies (including NASA) without a full-year appropriation, from 

12/21/18 through 1/25/19

FIGURE 3. NASA Continuing Resolution History—Fiscal Year (FY) 2008–2022
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AEROSPACE SAFETY ADVISORY PANEL

budget environment, engineering decisions are driven by short-term cost considerations that have 

long-term consequences for operations, safety, and risk posture. For example, integrated testing programs developed early on for sound technical reasons may get trimmed due to schedule and resource 

pressures, which increases operational risk. Optimal design solutions may be discarded to contend 

with immediate cost concerns, and thus thwart the opportunity to realize long-term savings and promote operational risk mitigation. Simply addressing the uncertainties and suboptimal phasing that are 

inherent in the current budget processes would go far toward allowing the Agency to manage risk better and make the difficult strategic decisions necessary to operate more efficiently.

While NASA must evaluate its structure, organizational dynamics, and culture to align to the new 

operating environment in which it finds itself, to be successful it also needs strong awareness and support from the stakeholder communities who must recognize their impact on the Agency’s ability to 

safely execute the nation’s space missions.

D. What Does Success Look Like?

In the ASAP Annual Report for 2020, we began a discussion of some strategic issues facing NASA in 

a rapidly evolving environment that we believe have significant impact on the safety and risk management of human space flight. In particular, we posed the following critical strategic considerations for 

the Agency:

f What role NASA intends to perform going forward and why.

f How the Agency will interact with both commercial and international partners.

f How the Agency will address shared risks.

f What management practices will be employed. 

f How the expectations will be communicated to its partners and to its workforce.

f How effective Systems Engineering and Integration (SE&I) will be accomplished.

f What the NASA workforce of the future should look like and how it will be achieved.

As NASA begins to answer these questions and craft the vision and principles that will guide the 

Agency for the next several decades, the Panel offers the following recommendations to help shape 

their efforts. 
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Recommendation 2021-05-01

NASA should develop a strategic vision for the future of space exploration and operations that 

encompasses at least the next twenty years, including potential alternative scenarios, that is 

driven by how the Agency is going to understand and manage risk in the more complex environment in which it will be operating

• The vision should describe the role that NASA intends to play during that period and how it 

plans to engage with both commercial and international partners

• NASA should assess the workforce, including the number, types, skills, experience, and 

responsibilities that will be required, and the infrastructure facility requirements, with a plan for 

managing changes needed to meet those requirements

• NASA should also propose general criteria for evaluating “make, manage, or buy” decisions 

on future programs or projects

• All aspects of the strategic vision and its implementation should be clearly and unambiguously communicated throughout the Agency

Recommendation 2021-05-02

As a part of an overall risk management approach and in order to develop and execute its strategic vision for the future of space exploration, NASA should establish and provide leadership 

through a “board of directors” that includes the Center Directors and other key officials, with 

the emphasis on providing benefit to the Agency’s mission as a cohesive whole, and not to the 

individual components of the Agency. The Board should act to identify the strategic risks and

obstacles that NASA may encounter in executing its mission, evaluate Agency-level mitigation 

approaches, and align the efforts of all Centers to ensure desired outcomes

Recommendation 2021-05-03

NASA should manage Artemis as an integrated program with top-down alignment, and designate 

a Program Manager endowed with authority, responsibility, and accountability, along with a robust 

bottom-up, collaborative feedback process for both Systems Engineering and Integration (SE&I) 

and risk management

These recommendations will be discussed in the subsequent sections of this report.
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III. Strategic Vision and Guiding Principles

The ASAP’s Annual Report for 2020 noted that the organizational structure, stakeholders, and characteristics associated with past NASA programs are very different from those present today (see 

Figure 4). The complexity of the missions and the variety of acquisition approaches has driven a much 

more challenging risk management and decision-making structure. In addition, the evolving dynamic 

of the human space flight sector—the many and multifaceted interactions across stakeholders, commercial suppliers, partners, and customers—creates a more challenging and complex day-to-day operating environment for NASA.

Historical

e.g., Apollo, Shutt

Today

e.g., Artemis, EDS

Gateway

Program Authority NASA NASA

For today’s 

environment...

What are NASA’s 

guiding principles 

and culture for NASA 

success?

Program 

Accountability NASA NASA

Program Responsibility Solely NASA Shared

Program Definition Single major program Many individual programs

Program Execution

Largely government 

with a single integrating 

contractor, international 

partners

Distributed, multiple 

suppliers, independent 

commercial efforts, 

international partners and 

competitors

Program Engineering PMO Engineer, Prime 

contractor Multiple, decentralized

Risk Ownership Centralized, NASA Decentralized, multiple 

owners

FIGURE 4. NASA’s Historical and Present Environments and Factors

Of particular importance, NASA is no longer the sole driver or customer for human space flight 

capabilities and related technology, nor is it the sole organization creating demand. NASA plays a critical role and responsibility in the space sector, however, particularly regarding risk management and 

acceptance, and the Agency’s decisions, opinions, and direction have weight and merit in the industry 

and across the globe. Consequently, it is imperative for NASA leaders to establish a clear vision of the 

future and an understanding of the Agency’s purpose to anchor its decisions today and tomorrow. A 

strategic vision, and a set of guiding principles—well communicated to NASA’s workforce and stakeholders—will help the Agency navigate the new environments within which it must operate to execute 
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government missions. In addition, such a top-down, strategically driven approach can expose and 

enable the organization to anticipate risks that otherwise might go unknown or unforeseen through 

an organic bottom-up approach. 

There are many methods by which an organization might develop such a strategic approach. 

Figure 5 provides one example. This construct is grounded in the key elements of any strategic plan: a 

focus on an organization’s leadership philosophy; the development of a strong, compelling, and clear 

vision; and a set of guiding principles. The entire organization can then anchor its day-to-day mission 

execution decisions to this foundational understanding. A strategic plan with these elements is then 

the basis for development of the tactical plans of action and policies required to achieve overall goals 

and major aims. The strategic plan can also inform organizational design, including the structure, systems, processes, workforce competencies, and infrastructure by which the Agency will execute its mission and mitigate risk.

Guiding 

Principles

• Purpose

• Culture

• Behavior

Vision

• Direction

• Inspiration

Goals and 

Objectives

Performance

• Product and 

Service Quality

• Customer Value

• Financial 

Performance

Environment

Leadership

• Functions

• Philosophy

• Form

Strategy

Structure

Systems

FIGURE 5. A Strategic Organizational Leadership Construct

The imperative for NASA to develop a strategic focus was at the heart of the ASAP 2020 Annual 

Report. In that report, the Panel asked NASA to consider a set of important strategic considerations 

described in Section II D, above. Regardless of what strategic organizational leadership construct 

NASA chooses to use, these critical questions implicate three main strategic elements that NASA must 

consider as it sets the Agency’s agenda: Vision, Leadership, and Guiding Principles. For each element, 

a set of guiding questions, noted below, can stimulate thinking as NASA works to define its role in the 

coming decades. Armed with answers to these questions in light of the seven critical strategic considerations, NASA can begin to set its path. The guiding questions by element include, but are not limited to, the following: 
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Leadership (Functions, Philosophy, Form)

f What are the key organizational attributes NASA will adopt to align and execute its strategic 

plan (collaboration, transparency, consensus, and with whom)?

f How will NASA interact with both commercial and international partners?

f What organizing constructs will NASA use to execute its approach?

f How will NASA get buy-in with its centers and external stakeholders?

f How will NASA create accountability to the strategic vision and plan?

Vision (Direction, Inspiration)

f What roles does NASA intend to perform going forward through Mars exploration and why?

f How will NASA fulfill the needs of the nation and the taxpayers?

f How will NASA be a leader, not a competitor, in the space market of the future?

f Who are NASA’s key stakeholders today and into the future?

f What does the NASA workforce of the future look like and how will it be achieved?

f What government and commercial infrastructure is necessary to fulfill this vision and how will 

this be acquired?

Guiding Principles (Purpose, Culture, Behavior)

f What are the inherent governmental functions for a national human space flight program that 

NASA must preserve?

f How will expectations be communicated to partners and to the workforce?

f What management practices will be employed?

f How will effective Systems Engineering and Integration (SE&I) be accomplished? 

f How is risk managed and accepted? How will the Agency address shared risks, and under what 

conditions?

f What are the inherent governmental functions for a national human space flight program that 

NASA must preserve?

There are many examples from across the whole of government, and even at NASA, where the 

answers to the above questions have created a strategic plan that was then successfully implemented. 

At NASA, the Apollo program, the conversion of NASA’s Kennedy Space Center to a multi-user 

spaceport, and the transformation of the NASA Mission Control Management Team are instances 

where a clearly articulated vision and guiding principles, wrapped in a thoughtful strategy, promoted 

change management, and resulted in the successful execution of complex projects. In the Department 

of Defense (DoD), the Navy Aegis Surface Combatant Program with its enduring five cornerstones of 

capability and the 2018 DoD National Defense Strategy also serve as examples where vision and strategic thought drove change and culture in mission execution.
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We recognize that, like any government or private organization, NASA is constrained by resources, 

which shapes the extent to which it can respond to strategic imperatives. NASA’s salient internal cost 

drivers are its workforce and infrastructure. Both encumber budget to maintain current staffing and 

systems and equipment, regardless of the program-specific work they do. Kept static, or flat, the same 

number of employees and pieces of equipment cost progressively more as prices escalate with inflation. These annually increasing costs then may consume more and more of the Agency’s budget if not 

deliberately managed—eventually crowding out the resources that could otherwise be applied to alternate strategies, new programs, and innovations. Moreover, once resource commitments are made, 

such alternatives become much more difficult to pursue. Any effort to initiate new projects or programs risks falling victim to suboptimal approaches focused on immediate needs. Some risks are tolerated that might have been managed differently and more effectively if resources were less constrained. 

Eventually these short-sighted solutions become entrenched. The momentum of existing projects and 

the constant juggling of resources become barriers to change even when team members recognize, “if 

we had it to do over, we wouldn’t do it this way.” Adding resources can help relieve this condition, but 

solutions can also be found in a careful strategic effort to align priorities from the top-down and to 

manage the enterprise more efficiently, thus freeing existing resources for alternate strategies, new programs, and innovations. 

Whether “right sizing” for efficiencies, shifting out of more ubiquitous capabilities and into more 

NASA-unique work, or simply freeing resources for innovation, technology development, and programmatic content, evolving the workforce is facilitated first by this same deliberate alignment. The 

alternative leaves the Agency in the difficult situation where the cost of just being in business consumes a growing fraction of NASA’s resources, at the same time the Agency is being asked to take on 

more and increasingly complex missions, leaving it with fewer options to manage cost, schedule, and 

technical risks.

Finally, culture is a key dimension of the context within which a strategic vision is framed, and 

that matures and evolves along with changing roles and responsibilities in the Agency. We remind 

NASA that a hallmark of any organization with a “generative,” or highly evolved safety culture is that 

there is, or should be, a chronic unease about safety. This unease, no matter how smoothly or successfully programs appear to be functioning, is what provides a hedge against complacency. The Panel does 

observe this unease, at times, during some discussions with NASA management. It is not observed 

consistently across all programs, with all providers, or with all levels of management, however. Over 

the coming year, the Panel will continue to ask questions in the vein of “what keeps you up at night,” 

and will regard forthright answers to these questions as an indication that NASA’s safety culture is 

maturing in an appropriate manner.

In sum, over the past several years, the ASAP has observed the development and maturation of 

various plans, structures, and processes, and these continue to shape the Agency’s ability to identify, accept, and mitigate risk. It is not yet evident, however, how these disparate efforts are aligned 

with and undergirded by a strong understanding of a top-down view of the agency’s purpose, vision, 
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AEROSPACE SAFETY ADVISORY PANEL

and guiding principles, especially as the organization moves into a future space sector growing ever 

more dynamic and complex. In fact, as the Panel has reviewed various programs, projects, and initiatives, issues symptomatic of a misalignment or absence of a broader cohesive strategic approach have 

emerged. This leads us to make the following recommendation:

2021-05-01: Development of Agency Strategic Vision for the Future of Space 

Explorations and Operations

NASA should develop a strategic vision for the future of space exploration and operations that 

encompasses at least the next twenty years, including potential alternative scenarios, that is 

driven by how the Agency is going to understand and manage risk in the more complex environment in which it will be operating

• The vision should describe the role that NASA intends to play during that period and how it 

plans to engage with both commercial and international partners

• NASA should assess the workforce, including the number, types, skills, experience, and 

responsibilities that will be required, and the infrastructure facility requirements, with a plan for 

managing changes needed to meet those requirements

• NASA should also propose general criteria for evaluating “make, manage, or buy” decisions 

on future programs or projects

• All aspects of the strategic vision and its implementation should be clearly and unambiguously communicated throughout the Agency
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Commercial Low-Earth Orbit 

Overview

NASA’s program to commercialize LEO provides a specific case study for the application of the 

principles described in Section III, albeit on a smaller scale than the Agency-wide strategy we 

advocate in this report. In the mid-2000s, when NASA established the Commercial Resupply 

Services (CRS) program, the Agency took the first step to open the aperture of space activities to 

private interests, and to start facilitating the growth of a new economic sphere—pursuits in space 

spurred by market forces instead of sole reliance on government funding. Since then, NASA has 

repeated that model with the Commercial Crew Program (CCP), and it is now looking at how to 

incorporate the same approach into the Artemis campaign. As NASA looks to expand its activities 

to cis-lunar space, the Agency expressed a desire to help “commercialize LEO” and thereafter instituted a series of tactical actions targeted at achieving that aim. 

Will NASA require specific engineering or operational skills to achieve its goals? Will it require 

a workforce with a deeper understanding of the acquisition processes and how to shape contracts 

for better risk management? As NASA looks to the future, what workforce does the Agency want 

to have? What will be the Agency’s enduring role in the effort to commercialize LEO? 

ASAP’s Observations

The ASAP has not been able to discern the overarching strategy, goals, and outcomes NASA is trying to achieve with the LEO commercialization effort, however. Applying a strategic approach to 

the LEO commercialization program, the Panel urges NASA to address the following questions: 

“What is NASA’s role in helping to create a commercial market in space and why is that role 

uniquely NASA’s?” The term “commercialize LEO” can mean different things to different people. Generally, though, the agenda concerns stimulating private investment in new exploration 

capabilities. While NASA is unique across all government agencies in its knowledge of the space 

environment, there are other branches of government better suited to molding and expanding the 

U.S. economy. Thus, NASA needs to clearly articulate what outcomes it seeks to achieve. In addition, creating an entirely new economic sphere will likely take a whole-of-government approach, 

raising questions about how and when NASA will bring talents and skills from other government 

entities to bear. A clear set of goals and outcomes will help shape the overall necessary approach, 

providing clarity for other agencies on possible roles.
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“How will the Agency interact with both commercial and international partners?” In the context of the goals the Agency has identified, what sectors and types of companies will NASA need 

to engage and how will they engage? Will there be a need to reach out to non-traditional sectors? 

How do the Agency’s targeted outcomes intersect with international interests, both for current 

partners and emerging space nations? 

“How will the Agency address shared risks?” One clear Agency goal the Panel understands is 

NASA’s desire to have a privately built and operated space station on orbit prior to the decommissioning of the ISS, allowing government-sponsored research and technology development to 

seamlessly continue in LEO. Shared risk management and workforce strategies are lacking, however. How, for example, will NASA ensure that human platforms provided by commercial providers are safe for NASA personnel? What is the risk profile NASA is willing to adopt to achieve 

desired outcomes? Additionally, it is unclear to the Panel what the anticipated outcome is for the 

Private Astronaut Missions project or how that activity fits into a larger strategy that advances the 

goal of establishing privately operated research platforms or other intended outcomes. Thus, it is 

hard to discern how NASA assesses the risks and rewards of sending private citizens to the space 

station. Finally, to be successful in achieving whatever outcomes the Agency targets, an honest and 

comprehensive strategically derived budget needs to be defined.

“What management practices will be employed?” and “How will the expectations be communicated to its partners and to its workforce?” What acquisition and partnering mechanisms 

are available to achieve the outcomes NASA identifies? What metrics will be used to determine if 

NASA’s goals are being met? 

“How will effective Systems Engineering and Integration be accomplished?” The SE&I mechanism NASA chooses to employ should be sufficient for the Agency to proactively understand and 

manage risk within the risk profile the Agency thinks is acceptable to achieve intended outcomes. 

“What should the NASA workforce of the future look like and how will it be achieved?” Will 

NASA require specific engineering or operational skills to achieve its goals? Will it require a workforce with a deeper understanding of the acquisition processes and how to shape contracts for 

better risk management? As NASA looks to the future, what workforce does the Agency want to 

have? What will be the Agency’s enduring role in the effort to commercialize LEO?
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IV. Agency Governance

The Panel sees direct links between executive expectations, governance approaches, leadership team 

performance, and risk management. As an agency with a long record of high-performing teams who 

manage the still-incredible risks associated with human space flight, we intend the following recommendation to help NASA’s executive leadership team leverage that same level of performance in formulating and executing its critical portfolio of current and future missions. 

2021-05-02: Establishment of an Agency “Board of Directors”

As a part of an overall risk management approach and in order to develop and execute its strategic vision for the future of space exploration, NASA should establish and provide leadership 

through a “board of directors” that includes the Center Directors and other key officials, with 

the emphasis on providing benefit to the Agency’s mission as a cohesive whole, and not to the 

individual components of the Agency. The Board should act to identify the strategic risks and

obstacles that NASA may encounter in executing its mission, evaluate Agency-level mitigation 

approaches, and align the efforts of all Centers to ensure desired outcomes

Though NASA has well-established executive management forums through which it deliberates 

various Agency decisions, it does not convene senior leaders as a strategic team with a holistic perspective on the Agency. Thus, the Panel recommends the Agency adopt a “Board of Directors”-like governance approach for its executives. Under this construct, the Administrator’s most senior Headquarters 

staff and the Center Directors would comprise an Agency steering committee with a deliberate 

Agency-level focus, rather than as representatives from and advocates for their areas of responsibility 

or field centers. 

NASA could convene this team in various ways, but it need not be a new or separate forum. 

Rather, NASA should set different engagement expectations for these leaders when they meet, in that 

they should “leave their individual program and/or Center hats at the door,” and focus on corporatelevel challenges, opportunities, and decisions driven by the best interests of the Agency and its ongoing missions. This imperative to focus on the entirety of the enterprise can help support the tough 

resource decisions necessary to contend effectively with the challenges of stakeholder demands, inevitable schedule pressures, and budget constraints. With NASA’s critical resources, workforce, and infrastructure largely managed at field centers incentivized to protect them, the Agency has struggled for 

many years to shift the workforce out of less critical work, or to divest obsolete facilities and infrastructure. This has added cost and manpower pressures to field centers that need margin for higher 

priority work, innovative solutions, and new opportunities. To escape the status quo—i.e., protecting budget, preserving the workforce configuration, maintaining every building and piece of major 
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AEROSPACE SAFETY ADVISORY PANEL

equipment—an explicit shift to an Agency-level focus is an essential start to reducing fixed costs and 

freeing more resources for new work in space exploration.

To maximize their leadership team’s performance, NASA executives will need to operate as a deliberately crafted high-trust team—a team that rests on shared competence and credibility to confront 

reality collaboratively. One source of insight for how NASA could improve trust within its executive 

team is Stephen M.R. Covey’s The Speed of Trust in which he presents a simple inventory of behaviors 

that are prevalent in low- and high-trust organizations, as shown in Table 1. 

TABLE 1. Cultural Behaviors in Low and High Trust Organizations

(Source: The Speed of Trust: The One Thing That Changes Everything; 

Stephen M.R. Covey, shared with permission and all rights reserved by Franklin Cove

Low-Trust Organizations High-Trust Organizations

People manipulate or distort facts There is real communication and real 

collaboration 

People withhold and hoard information Information is shared openly

Getting the credit is very important People share credit abundantly

People spin the truth to their advantage People are candid and authentic

New ideas are openly resisted and stifled The culture is innovative and creative

Mistakes are covered up or covered over Mistakes are tolerated and encouraged as a way 

of learning

Most people are involved in a blame game, 

bad-mouthing others People are loyal to those who are absent

There are numerous “meetings after the 

meetings” There are few “meetings after meetings”

There are many “undiscussables” Transparency is a practiced value

People tend to overpromise and underdeliver There is a high degree of accountability

There are a lot of violated expectations, for 

which people try to make excuses

People pretend bad things aren’t happening or 

are in denial People talk straight and confront real issues

The energy level is low There is a palpable vitality and energy–people 

can feel the positive momentum

People often feel unproductive tension–

sometimes even fear

As the “Board of Directors” works to eliminate low-trust behaviors in favor of high-trust behaviors, intra-team communication will become more transparent. And, as they engage from an Agencyperspective in this team environment, they are able to pool the insights and expertise from their 

areas of responsibility and their individual experience on behalf of the full team and achieving more 
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effective strategic-level outcomes becomes possible. In this way, the “Board” can be more deliberately 

aligned in their role as NASA’s guiding coalition, engaging in all Agency-level strategic decision-making, not to serve parochial single-center needs, but to set a top-down sense of purpose and priorities, 

which then influence Agency and Center strategies and actions. 

Specifically, such alignment enables leaders to identify and relinquish legacy paradigms that do not 

serve future needs, articulate program objectives and risk management expectations, realign and optimize human capital and infrastructure, and invest in new missions and the capabilities that best serve 

them. Importantly, however, transparent communication and high-trust levels cannot be left to good 

intentions. For transparence and trust to characterize leadership team engagement, Center Directors 

and other “Board” members should be incentivized and selected for demonstrating and fostering these 

behaviors in their daily work.

Finally, for this model to have greatest impact, transparent communication within the “Board of 

Directors” must propagate down each principal’s management lines, enabling the full management 

team and workforce across NASA to both understand and deliberate a common set of challenges, 

opportunities, and choices. This both aligns NASA’s workforce in support of Agency priorities and 

facilitates feedback to the “Board” that can further improve effectiveness. 

V. Program Management Across the NASA Enterprise

As a global leader in human spaceflight, NASA has had tremendous successes throughout its history, 

and much of that success has stemmed from strategic, coherent program management, expert leadership, and clarity of purpose and process from the top down. As with many of this nation’s most successful strategic efforts, NASA placed priority on program management approaches that valued clear 

lines of authority, a coherent resource management approach, and a transparent yet comprehensive 

roadmap for integrated risk management. For reasons stated previously in this report, however, NASA 

has deviated from previous program management “best practices” that have been hallmarks of successful strategic programs. During this past year, the Panel had numerous opportunities, during quarterly 

meetings as well as special discussions, to better understand how the myriad programs and projects 

that collectively contribute to the objectives of Artemis will be brought together as a cohesive campaign, and the Panel now notes several deviations from NASA’s history that give cause for concern. 

1. There is no top-level Artemis program—and therefore no Artemis Program Manager—to 

provide comprehensive and aligned integrated guidance that directs resources of all 

Artemis programs and projects in a cohesive manner to manage the overall risk.

As we’ve noted, the EGS, Orion, and the SLS were set up as three individual programs, each with their 

own processes and structures—rather than what previously would have been an integrated single program. Ordinarily, the resulting critical gap in systems integration would have been filled by a single 
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overarching program. Since this does not exist, the Agency is attempting to manage the systemic risks 

of the Artemis enterprise in the structure they have adopted without deliberately assessing whether 

that structure is best suited for the necessary purposes of broad integration and enterprise risk management. Specifically, at this point, the Artemis campaign is not established formally as an “Artemis 

program”—there is no designated Program Manager who has program management authority over 

all aspects of Artemis developments across the enterprise. Although NASA used a well-developed program management structure for the Apollo, Space Shuttle, and ISS programs of the past, there is no 

similar unifying and comprehensively aligned program framework for the Artemis enterprise. In other 

words, there is no clearly defined leader of the enterprise, transparently endowed with the ultimate 

authority, responsibility, and accountability to direct all Artemis-related programs and ensure full synchronization and integration of effort (see Figure 6). 

The Gateway

Airlock 

(provider TBD)

CSA

Robotic 

system

ESA

ESPRITRefueler

SpaceX

Co-manifested PPE/HALO

Launch Vehicle (not pictured)

Maxar

Power and Propulsion 

Element (PPE) 

SpaceX

Logistics 

Module

JAXA

HTV-XG 

Resupply 

(proposed)

ESDMD Artemis Elements, Partners, and Providers 

ESA 

JAXA

International 

Habitat (I-HAB)

Surface 

Habitat

Pressurized rover 

Lunar 

Terrain 

Vehicle

Advanced 

spacesuits 

Imagery not to scale

Potential US industry and 

international participation:

Cargo 

Logistics 

Lander

Human Landing 

System (HLS) 

SpaceX

First surface mission 

crew demo

(subsequent HLS service 

providers TBD)

Northrop Grumman 

ESA

JAXA

Habitation and 

Logistics Outpost 

(HALO)

Lockheed Martin

ESA

European Service Module

Lockheed Martin

Launch Abort System

Northrop Grumman

Launch Abort System 

Motors

Dynetics

Universal Stage Adapter

Boeing

Exploration Upper 

Stage, Interstage, and 

Core Stage 

Aerojet Rocketdyne

Exploration Upper 

Stage RL10 Engines

Northrop Grumman

5-Segment Solid 

Rocket Boosters

Aerojet Rocketdyne

RS-25 Engines

(govt. reference design 

shown here)

Surface systems

Orion spacecraft

Additional elements, systems, and subsystems yet to be 

determined or not pictured on this graphic will be provided 

by NASA’s commercial and international partners. 

Space Launch System (SLS)

(Block 1B Crew shown)

Content as of 12/03/21

US industry provider TBD:

FIGURE 6. Complexity of Artemis—Commercial and International Components

Instead, NASA has undertaken a number of new integrating efforts in an attempt to fill the void. 

There is an integrating manager who has created various processes that primarily rely on a broad series 

of boards and panels to perform a “bottoms-up” review process, designed to raise issues and resolve 

integration questions as they arise through day-to-day program work. The sheer number of programmatic efforts within the enterprise make it unclear whether the critical integrated risk management 

outcomes are fulfilled by this approach, however. In particular, the ASAP is concerned about the 

heavy reliance on lower-level workers to raise integration concerns across sub-programs. Without a 
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comprehensive and accountable approach to integrated risk management from the enterprise level, the 

workforce responds to a large bureaucracy of panels and boards, without authoritative guiding principles (e.g., an Artemis Systems Engineering and Integration Plan) and transparent direction on roles, 

responsibilities, and authorities for sub-program risk integration. As key resource decisions that may 

affect integrated risk are made, it is unclear who is accountable—who specifically is accepting that risk. 

Although NASA has no Artemis program, nor a Program Manager, NASA markets the Artemis 

effort as a “program” in its Artemis Plan, available on NASA’s website: (https://www.nasa.gov/sites/

default/files/atoms/files/artemis_plan-20200921.pdf). The use of the word “program” to describe this 

human endeavor makes sense, given NASA’s history. The term “program” signals adherence to a shared 

body knowledge and experience about how integrated program management flows from an accountable program manager at the top who strategically directs all programmatic interconnections across 

the defined enterprises. Given NASA’s historical culture of using this top-level program as an organizing framework for highly complex human space flight campaigns, NASA’s use of the phrase “Artemis 

program” without actually employing a program of architecture risks is confusing both employees 

and contractors about who is ultimately responsible and accountable. Ensuring that NASA employees 

clearly understand roles, responsibilities, and authorities surrounding the Artemis enterprise has been 

an ongoing concern, and leads the Panel to the following recommendation: 

2021-05-03: Establishment of an Artemis Integrated Program

NASA should manage Artemis as an integrated program with top-down alignment, and designate 

a Program Manager endowed with authority, responsibility, and accountability, along with a robust 

bottoms-up, collaborative feedback process for both Systems Engineering and Integration (SE&I) 

and risk management

2. There is no Artemis prime integrating contractor in support of the NASA workforce.

Artemis is by far the most complicated human space flight endeavor that NASA has ever attempted. 

Sub-programs across the entire Agency, along with international partners, and contractual arrangements for highly complex services such as the Human Lander System (HLS) are spread across multiple centers and encompass countless SE&I points across the enterprise. In the past, NASA has heavily 

leveraged a single integrating contractor who works across all elements of the system (e.g., USA for the 

Space Shuttle program and Boeing for the ISS program) to perform the critical aspects of managing 

the SE&I across sub-programs and projects, and to ensure there is consistency of standards, practices, 

and development outcomes for NASA’s human space flight programs. At this point in the Artemis 

campaign, each sub-program has designated its own integrating contractor, and there is no support 

contractor who has the “whole picture view” of how the entire campaign must come together with 

consistent risk management approaches. It is unclear how much NASA may be paying for duplication 
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of effort across programs, projects, and centers, or whether the work myriad integrating contractors 

perform is consistent or in conflict. Since a Prime Integrating Contractor has often been responsible for risk management integration throughout development in previous programs, the Panel advises 

NASA to gain clarity on how this deviation from previous program practices is achieving equivalent 

risk management outcomes. 

3. An unprecedented mix of acquisition approaches presents risk management challenges.

Best practice dictates that an acquisition “life cycle” should encompass transparent and unambiguous 

authorities, responsibilities, and a chain of accountability for the entire development cycle, across all 

entities participating in the development. Contractual instruments should then clarify these authorities and responsibilities. An overarching blueprint for acquisition, oversight requirements, and insight 

should thus be aligned to a well-defined, comprehensive NASA risk management strategy and promulgated to all contracts in such a way as to ensure that overall integrated risk management—from 

project-to-project, program-to-program, and mission-to-mission—is clear, consistent, and coherent. 

Every acquisition, whether a contractor supporting a NASA in-house program such as SLS, or a “service contract” such as HLS, should have a consistent, unambiguous approach to risk management that 

spans the entire enterprise. Beyond this, the public’s trust in NASA as the Nation’s steward of human 

space flight demands that the Agency ensure accountability for risk management is very clear. 

In this context, NASA has settled on a broad mixture of acquisition approaches to achieve the outcomes of the Artemis campaign, but it is unclear whether these contracts are synchronized to ensure 

responsibilities are consistently explained, authorities are cogently defined, and accountabilities are 

applicable for a highly complex, SE&I context. 

As an example of the challenges NASA faces in this regard, the night landing of the SpaceX 

Crew-1 (see Figure 7), though successful, revealed a concerning dissonance. The Panel learned from 

discussions with CCP management earlier this year that prior to the landing, NASA and SpaceX had 

differed in their understanding of the level of risk to be incurred, and that last-minute communications had been necessary to ensure NASA approved the plans for the night landing. NASA had understood prior to the mission that a daytime landing was the lowest risk option. SpaceX understood that 

a night landing was within design ratings, and furthermore, weather conditions and sea states at night 

are often better for landing. In this case, the conditions on the night of the landing were optimal, but 

according to weather forecasts at the time, the daytime sea state conditions would likely have introduced unnecessary hazards. Last-minute communications and decisions made under these circumstances could have resulted in a poor decision, due to immense operational pressures. NASA and 

SpaceX should have had a common understanding of relative risk levels and of the lines of communication and authority well before the mission—and certainly before a last-minute NASA approval was 

needed for the landing plans.

As another example, Boeing began 2021 having just begun to implement the recommendations 

of the Joint Independent Review Team (JIRT), which was established following the anomalous first 
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Orbital Flight Test (OFT-1) in December of 2019. By late 2021, all JIRT recommendations had been 

implemented. Improvements included changes to the software certification strategy. In July 2021, an 

FRR for a second uncrewed orbital flight test (OFT-2) was conducted, just days before the scheduled launch of OFT-2. Propulsion system issues with the Starliner—specifically, the troubleshooting 

that was necessary when several propulsion system valves were determined to have been in the wrong 

position—caused an indefinite delay. The Panel’s concern is that during the OFT-2 Flight Readiness 

Review (FRR), NASA and Boeing differed in how they characterized the risk that was brought to light 

by the stuck propulsion valves. Boeing’s risk posture, communicated as “low,” was related to its contractual requirements, while the NASA team evaluated the risk, communicated as “moderate,” in a 

broader mission context. While the ultimate decision was to troubleshoot the stuck valves, the FRR 

revealed NASA and Boeing do not share a common understanding of how to assess and characterize risk. Equally disturbing was that the program got very close to launching the spacecraft before the 

stuck-valve issue was identified. This is exactly the type of situation that the Panel urges NASA to 

aggressively avoid as the Agency proceeds with assigning Artemis contracts. 

FIGURE 7. Crew-1 Night Landing
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The Panel strongly advises that NASA ensure the guiding principles of inherent governmental functions are clearly articulated, and through a centrally managed contracts strategy, acquisitions 

are clearly aligned to an overall risk management strategy and a clear framework for each contractual 

approach. NASA appears to be buying some high-risk capabilities, such as the HLS, as a “service,” but 

it must nonetheless ensure that those inherent governmental functions related to risk management 

and safety of flight are clearly specified in contracts, and that the custody of accountability remains 

transparent and enforceable. As necessary, NASA systems engineers should be explicitly assigned contractual duties that fit their required responsibilities.

4. Regardless of whether a partner-approach or an acquisition-approach is used, consistent expectations of transparency and data-driven risk discussions are required. 

The Panel continues to be concerned about cracks discovered in the hull of the ISS service module transfer tunnel that manifested as an increased leak rate in 2019. In early 2021, two cracks in the 

pressure shell were repaired, which reduced the leak rate but did not fully mitigate it. Now, two years 

after the cracks were initially discovered, the investigation of root cause(s) continues. The Panel continues to follow this issue closely, both through updates on the root cause investigations and the operational procedures established to manage the risk. Likewise, the Russian Multipurpose Laboratory 

Module (MLM) also has the Panel’s attention. The MLM experienced in-flight anomalies on the 

day of launch. The Russian team worked around these anomalies, but when the MLM docked eight 

days later, it experienced more anomalies during the post-contact steps during docking. Each of these 

anomalies represents the fundamental risks the ISS program must continue to manage; problems 

attributable to an aging station and human errors that can lead to unsafe operations. 

To minimize anomalies, and mitigate their impact when they do occur, requires transparency 

between partners and private industry. NASA must set the expectation and standards for transparency 

and data-driven discussions required for operating in the more high-risk missions of the future. Of 

special importance is that these discussions take place in a proactive pre-crisis environment, not solely 

in reaction to a dynamically evolving crisis. Moreover, the ISS program must continue to be vigilant 

and drive investigations that uncover root cause(s) and effects for all anomalies to ensure the equipment is continuing to perform as expected, and that the operational community maintains its knowledge and training at the required levels to safely operate the space station. The same standards must 

apply to all partners and private companies that are involved in NASA missions, regardless of contract 

structure or partner type. 
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VI. Congressional Actions 

For several years, the Panel has expressed concern with the risk orbital debris poses to orbiting spacecraft 

and transiting astronauts. The hazard from orbital debris has been recognized as a major issue in every program. It is the dominant contributor to the calculations of loss-of-crew predictions for both commercial 

crew vehicles and Orion, and it has been a factor in two of the top safety risks for the ISS. NASA declared 

it an Enterprise Risk in 2017. The ISS has been maneuvered over two dozen times since its inception to 

avoid collision with orbital debris, and such maneuvers now seem necessary even more often. 

Space has become more congested, and the problem of orbital debris in space is growing at a concerning pace. CubeSats and other small satellites are being launched more frequently, and several companies are now deploying mega-constellations with hundreds, or even thousands, of satellites. Some of 

these satellites incorporate the use of electric propulsion and autonomous on-board maneuvers with 

very short turnaround times, increasing the difficulty of tracking and planning for collision avoidance. On a global level, across the full international inventory, several close calls occur weekly between 

numerous space objects, many of which are not capable of maneuvering out of harm’s way. The debris 

issue recently took a sudden turn for the worse in November of 2021, when a Russian anti-satellite test 

destroyed the Russian Kosmos 1408 satellite and significantly contributed to the debris field near the 

altitudes of the ISS. 

The risks to the space environment and to all who use it must now be actively managed on a continuous basis, with robust tracking sensors, timely data, high-precision predictive algorithms, and—

similar to air traffic control—a tight network between those who track and those who are tracked, 

to ensure appropriate warnings are disseminated, acknowledged, and if possible, acted upon to avert 

catastrophe. The national approach to this issue has not been fundamentally revised in many years, 

leading to archaic methods and analyses, and incoherence among numerous autonomous tracking services. While the ASAP is principally focused on the serious hazards to NASA spacecraft and astronauts, the Panel recognizes this issue must be tackled on a broad front. In our 2017 Annual Report, we 

warned that “the U.S. government should seriously consider implementing significant improvements 

for Space Situational Awareness analyses and the provision of Space Traffic Management services, as 

well as expand its efforts in developing international strategies to reduce orbital debris generation in 

the future.” The Panel further asserted it was important for “the U.S. to take a leadership role and for 

the National Space Council to address” the risk, and that the Panel believed “a lead Agency in the U.S. 

should be assigned to spearhead and coordinate efforts to prevent the generation of new debris and 

reduce hazards posed by existing debris.”

The Panel continues to be concerned that Congress and the Administration have not yet reached 

an agreement on the necessary actions required to address this issue, rendering the U.S. government, 

industry and research partners, and international stakeholders unable to move forward in a fully 

coherent manner to materially reduce orbital debris risks and to increase the sustainability of space as a 

global strategic domain. It is well overdue for the U.S. to exert effective international leadership in the 
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safety of space operations by 1) designating and funding a Lead Agency to provide timely and actionable safety data to all space operators; 2) working proactively within government, with industry, and 

in partnership with the international community to develop standards, guidelines, best practices, and 

“rules of the road” for safe space operations; and 3) supporting the conduct of scientific research and 

technology development for related areas, such as improved sensors, software, constellation management techniques, and methods for active debris management.

In the Annual Report for 2020, the Panel outlined the actions needed by Congress:

2020-03-01: Designation of a Lead Federal Agency for Civil Space Traffic 

Management

The Panel recommends the following for Congress:

• Designate a Lead Federal Agency for Civil Space Traffic Management

• Provide that agency with authority, immunity from lawsuits, and resources to do the job

• In addressing the Space Traffic Management issue, require whole-of-government engagement, public-private partnerships, and collaboration between government, industry, academia, and the international community

In summary, the Panel continues to contend that the issue of orbital debris not only presents a 

standing safety concern for NASA, and commercial providers, especially for human-tended spacecraft, 

but it is also a growing threat to the sustainability of space as a peaceful domain for science, exploration, innovation, and commerce. It is the Panel’s hope that comprehensive actions are soon taken by 

Congress—and by NASA in support—to advance risk reduction in a strategic and coherent manner. 

Additionally, as far back as 2015, the ASAP noted that the specific language in the NASA 

Authorization Act of 2005 concerning Human Space Flight Independent Investigations, while perhaps appropriate and logical for the ISS and Space Shuttle, was inadequate and obsolete for the emerging environment that included reusable and commercially provided space vehicles. In 2015, the ASAP 

made the following recommendation:

2015-05-02: Human Space Flight Mishap Response Procedure

The 2005 Authorization language should be reviewed with today’s systems in mind...including 

details on the level of vehicle damage requiring investigation, the temporal issues of when mission phases begin and end, and NASA’s oversight role in mishap investigations conducted by its 

providers, as well as when the need for oversight is required. The mishap response procedures

should be thought through, documented, and in place well before any actual flights
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The 2005 Authorization language is even more inadequate when considering the emerging space 

travel involving non-NASA participants. Yet this recommendation remains open and increasingly 

relevant. 

VII. Forward Work 

As the Agency proceeds with caution in accordance with White House and Centers for Disease 

Control guidance, the ASAP anticipates conducting its 2022 program of work with in-person insight, 

fact-finding, and quarterly meetings. Much of our focus will remain on the strategic issues we have 

discussed in this report. In addition, we intend to delve more deeply into specific safety and risk management issues of Artemis as a whole, its components—especially the HLS and the extravehicular 

mobility units—and the requisite integration. We will continue to probe the ongoing CCP and the 

progress of Starliner, the health and safe operation of the ISS—with plans for maintaining a secure 

location for risk reduction efforts in LEO—including the LEO commercialization approaches, and 

the Artemis I and II progress. 

A new item on our plate will be to look at the emerging potential for expanded opportunities for a 

wider variety of individuals to visit space. While it is tempting to compare this to the growth of commercial aviation nearly a century ago, there are very important differences. The physiologic stresses of 

space flight are more significant than those experienced by passengers in atmospheric flight. Medical 

or behavioral health events onboard a spacecraft also pose more significant challenges to address than 

those same events occurring during commercial atmospheric flight. Passengers in spacecraft are an 

intimate part of the operational environment, and any medical or behavioral event that occurs can 

have a profound impact on crew operations, as well as on crew and mission safety. NASA and international partner medical authorities—with decades of experience in space medical certification and 

mission medical management—are in a unique position to support the commercial space flight industry in enabling more people to safely experience space flight. NASA and the ISS medical systems continue to facilitate and support tourist visits to the ISS, building an important health and medical 

experience base. 

The European Space Agency announced the Para Astronaut Feasibility Project early in 2021, which 

invited application to their astronaut program for people who have met all qualifications required to 

become an astronaut, as well as for people with certain lower-limb deficiencies and persons of short 

stature. In January 2021, President Biden signed an Executive Order on Preventing and Combating 

Discrimination on the Basis of Gender Identity or Sexual Orientation. NASA medical authorities continue working to determine how medical standards can be adjusted to broaden opportunities for people with certain disabilities. The Panel will follow the developing health and medical support for more 

people to fly in space with great interest from a safety perspective.
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VIII. Conclusion

The space sector, both domestically and internationally, is rapidly transforming. More nations are 

engaged in space activities than at any point in history, and private industry is recognizing the economic value of the space domain. Sixty years of NASA’s efforts and U.S. government investments 

have been instrumental in the establishment of the foundational knowledge leveraged by the world. 

As NASA looks to the future and moves to expand human knowledge and operational capabilities 

beyond LEO, it must recognize and adapt to the new environment and decide strategically how to 

forge humanity’s path outward while managing the risks in an appropriate manner.
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APPENDIX A 

Summary and Status of Aerospace Safety Advisory Panel (ASAP) 

Open Recommendations

2021 Recommendations1

2021-05-01: Development of Agency Strategic Vision for the Future of Space 

Explorations and Operations

Finding: For NASA to continue its trajectory of success in the decades ahead, it must proactively plan 

for and manage its work in the presence of the numerous challenges, constraints, and risks inherent in 

the changing environment of the aerospace community.

Recommendation: NASA should develop a strategic vision for the future of space exploration and 

operations that encompasses at least the next twenty years, including potential alternative scenarios, 

that is driven by how the Agency is going to understand and manage risk in the more complex environment in which it will be operating.

f The vision should describe the role that NASA intends to play during that period and how it 

plans to engage with both commercial and international partners.

f NASA should assess the workforce, including the number, types, skills, experience, and responsibilities that will be required, and the infrastructure facility requirements, with a plan for managing changes needed to meet those requirements.

1 Note on colors: Red highlights what the ASAP considers to be a long-standing concern or an issue that has not yet been adequately 

addressed, or for which there is no identified resolution. Yellow highlights an important ASAP concern or issue that the Panel is not 

confident is being addressed adequately, or where a resolution has been identified but does not yet have a defined implementation plan. 

 Green indicates a positive aspect or concern that is being adequately addressed but continues to be followed by the Panel. No color 

indicates that the ASAP has not received a response.
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f NASA should also propose general criteria for evaluating “make, manage, or buy” decisions on 

future programs or projects.

f All aspects of the strategic vision and its implementation should be clearly and unambiguously 

communicated throughout the Agency.

Rationale: NASA is no longer the sole driver or customer for human space flight capabilities and 

related technology, nor is it the sole organization creating demand. NASA, however, still has a critical role and responsibility in the space sector, and the Agency’s decisions, opinions, and direction have 

weight and merit in the industry and across the globe. Consequently, it is imperative for NASA leaders to establish a clear vision of the future and an understanding of the Agency’s purpose to anchor 

its decisions today and tomorrow. A strategic vision, and a set of guiding principles—well communicated to NASA’s workforce and stakeholders—will help the Agency navigate the new environments 

within which it must operate to execute government missions. In addition, such a top-down, strategically driven approach can expose and enable the organization to anticipate risks that otherwise might 

go unknown or unforeseen through an organic bottoms-up approach. 

 OPEN  NASA’s response not provided at time of ASAP Annual Report 2021 printing

2021-05-02: Establishment of an Agency “Board of Directors”

Finding: Over the decades, at various times with varying amounts of success, NASA leadership has 

sought to create an Agency-wide identity to foster greater coordination. There remains, however, a 

very strong and separate culture at each NASA Center, which drives the Centers to prioritize their own 

goals rather than those of the overall Agency. In turn, this creates pressure against the implementation 

of a strategic approach that aligns the whole organization to a common set of goals. Importantly, moreover, the resource flow remains Center-focused rather than optimized around integrated outcomes.

Recommendation: As a part of an overall risk management approach and in order to develop and execute its strategic vision for the future of space exploration, NASA should establish and provide leadership through a “board of directors” that includes the Center Directors and other key officials, with 

the emphasis on providing benefit to the Agency’s mission as a cohesive whole, and not to the individual components of the Agency. The Board should act to identify the strategic risks and obstacles that 

NASA may encounter in executing its mission, evaluate Agency-level mitigation approaches, and align 

the efforts of all Centers to ensure desired outcomes. 

Rationale: Although NASA has well-established executive management forums through which 

it deliberates various Agency decisions, it does not convene senior leaders as a strategic team with 
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a holistic perspective on the Agency. Thus, the Panel recommends the Agency adopt a “Board of 

Directors”-like governance approach for its executives. Under this construct, the Administrator’s most 

senior staff at Headquarters and the Center Directors would comprise an Agency steering committee 

with a deliberate Agency-level focus, rather than as representatives from and advocates for their areas 

of responsibility or field centers. 

NASA could convene this team in various ways, but it need not be a new or separate forum. 

Rather, NASA should set different engagement expectations for these leaders when they meet, in that 

they should “leave their individual program and/or Center hats at the door,” and focus on corporatelevel challenges, opportunities, and decisions driven by the best interests of the Agency and its ongoing missions. This imperative to focus on the entirety of the enterprise can help support the tough 

resource decisions necessary to contend effectively with the challenges of stakeholder demands, inevitable schedule pressures, and budget constraints. With NASA’s critical resources, workforce, and infrastructure largely managed at field centers incentivized to protect them, the Agency has struggled for 

many years to shift the workforce out of less critical work, or to divest obsolete facilities and infrastructure. This has added cost and manpower pressures to field centers that need margin for higher priority 

work, innovative solutions, and new opportunities. To escape the status quo—i.e., protecting budget, 

preserving the workforce configuration, maintaining every building and piece of major equipment—

an explicit shift to an Agency-level focus is an essential start to reducing fixed costs and freeing more 

resources for new work in space exploration.

 OPEN  NASA’s response not provided at time of ASAP Annual Report 2021 printing

2021-05-03: Establishment of an Artemis Integrated Program

Finding: NASA has deviated from previous program management “best practices” that have been 

hallmarks of successful strategic programs. During this past year, the Panel had numerous opportunities, during quarterly meetings as well as special discussions, to better understand how the myriad programs and projects that collectively contribute to the objectives of Artemis will be brought together as 

a cohesive campaign, and the Panel notes several deviations from NASA’s history that give cause for 

concern. The ASAP finds three areas of concern: 

1. There is no top-level Artemis program, and therefore no Artemis Program Manager, to provide 

comprehensive and aligned integrated guidance that directs resources of all Artemis programs 

and projects in a cohesive manner to manage the overall risk. 

2. No Artemis prime integrating contractor exists in support of the NASA workforce.

3. An unprecedented mix of acquisition approaches presents risk management challenges.
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Recommendation: NASA should manage Artemis as an integrated program with top-down alignment, and designate a Program Manager endowed with authority, responsibility, and accountability, along with a robust bottoms-up, collaborative feedback process for both Systems Engineering and 

Integration (SE&I) and risk management.

Rationale: As with many of this nation’s most successful strategic efforts, NASA placed priority on 

program management approaches that valued clear lines of authority, a coherent resource management approach, and a transparent yet comprehensive roadmap for integrated risk management. NASA 

has deviated from previous program management “best practices” that have been hallmarks of successful strategic programs. The Agency is attempting to manage the systemic risks of the Artemis 

enterprise in the structure they have adopted for Exploration Ground Systems, Orion, and the Space 

Launch System, without deliberately assessing whether that structure is best suited for the necessary 

purposes of broad integration and enterprise risk management. Concerns involving the absence of 

1) a designated Program Manager with program management authority over all aspects of Artemis 

developments across the enterprise; 2) a designated Prime Integrating Contractor responsible for risk 

management integration; and 3) a congruent acquisition life-cycle approach suitable to ensure an 

overarching blueprint for acquisition, oversight requirements, and insight have prompted the Panel to 

advise NASA to gain clarity on how this deviation from previous program practices is achieving equivalent risk management outcomes.

 OPEN  NASA’s response not provided at time of ASAP Annual Report 2021 printing
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Open Recommendations from Prior Years

2020-03-01 Designation of a Lead Federal Agency for Civil Space Traffic 

Management (Congress)

Finding: For several years, the Panel has expressed concern with the risk of damage to orbiting spacecraft and transiting astronauts due to micrometeoroids and orbital debris (MMOD). The hazard from 

MMOD has been recognized as a major issue in every program. MMOD is the dominant contributor 

to the calculations of loss-of-crew predictions for both commercial crew vehicles and Orion, and it has 

been a factor in two of the top safety risks for the International Space Station (ISS). NASA declared it 

an Enterprise Risk in 2017.

Recommendation: The Panel recommends that the Congress:

f Designate a Lead Federal Agency for Civil Space Traffic Management.

f Provide that agency with authority, immunity from lawsuits, and resources to do the job.

f In addressing the Space Traffic Management issue, require whole-of-government engagement; 

public-private partnerships; and collaboration between government, industry, academia, and 

the international community.

Rationale: The hazard persists and continues to grow exponentially. Space is becoming more congested. For example, CubeSats and other small satellites are being launched with increasing frequency, 

and several companies are now deploying mega-constellations with hundreds, or even thousands, of 

satellites. Some of these satellites incorporate the use of electric propulsion and autonomous onboard 

maneuvers with very short turnaround times, increasing the difficulty of tracking and planning for 

collision avoidance. 

It is important to recognize the prevalence of the issue. Orbital debris events and close calls are not 

rare, but they are in fact becoming more and more frequent as space becomes more congested and as 

national and international space players—who rightfully seek to leverage the high ground of space for 

commerce, science, and national prestige—continue to populate the space domain with new satellites. 

The risks are growing, and a more strategic approach to the problem is now necessary to arrest the risks 

and to assure that the domain of space remains sustainable.

NASA currently has 20 missions in low-Earth orbit, and the Agency definitely takes the risk 

seriously. But the issue is larger than NASA—it affects and is affected by all entities that conduct 

operations in space, and it endangers all of those functions on which the public has come to rely—

communications, navigation, weather prediction, to just start the list. While the ASAP is principally 

focused on the serious hazards to NASA spacecraft and astronauts, the Panel recognizes that the issue 

must be tackled on a broader front. 
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The Panel was encouraged in 2018 when the National Space Council issued Space Policy Directive-3 

(SPD-3), the National Space Traffic Management Policy, which acknowledged and addressed this 

issue and the need to improve Space Situational Awareness and Space Traffic Management. SPD-3 

promoted the implementation of a number of steps to address the orbital debris risk and recommended that the Department of Commerce take responsibility for implementing a Civil Space Traffic 

Management framework. The Panel is dismayed that Congress and the Administration have not yet 

reached an agreement on the appropriate response to that recommendation, resulting in departments 

and agencies not being able to move forward on implementing a framework that will both materially 

reduce the Space Traffic Management risks and increase the sustainability of space as an international 

strategic domain.

It is well overdue that the United States exert some effective international leadership in the safety 

of space operations and begin doing so by designating—including providing authority and resources 

to—a Lead Agency to see to the provision of timely and actionable safety data to all space operators; 

work proactively within government, with industry, and in partnership with the international community in developing standards, guidelines, best practices, and “rules of the road” for safe space operations; and support the conduct of scientific research and technology development for related areas, 

such as improved sensors, software, constellation management techniques, and methods for active 

debris management.

 OPEN  The chairman of the Senate Committee on Commerce, Science, and Transportation has 

introduced the Space Preservation and Conjunction Emergency (SPACE) Act, which would authorize the Department of Commerce to provide space situational awareness services to civil, commercial, and international space operators. However, even if the SPACE Act is eventually approved

by Congress, and signed into law by the President, it would still be necessary for Congress to provide the necessary budget and staffing resources through the appropriations process before any 

significant actions could be taken to implement the Act

2020-03-02 Designation of a Lead Federal Agency for Civil Space Traffic 

Management (NASA)

Finding: For several years, the Panel has expressed concern with the risk of damage to orbiting spacecraft and transiting astronauts due to micro-meteoroids and orbital debris (MMOD). The hazard 

from MMOD has been recognized as a major issue in every program. MMOD is the dominant contributor to the calculations of loss-of-crew predictions for both commercial crew vehicles and Orion, 

and it has been a factor in two of the top safety risks for the International Space Station (ISS). NASA 

declared it an Enterprise Risk in 2017.
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Recommendation: The Panel recommends that NASA:

f Support and partner with the Lead Federal Agency once one is selected.

f In the interim period:

• Because of the direct relationship to astronaut and spacecraft safety, ensure that risks having to do with MMOD, Space Situational Awareness, and Space Traffic Management are 

addressed in NASA’s ongoing activities and in future budget requests.

• In collaboration with other government agencies and industry, develop and publish guidelines for Space Traffic Management focused on current and emerging challenges to maintain the safety of astronauts and spacecraft.

• Develop a proposal for a Space Traffic Management technology roadmap.

Rationale: The hazard persists and continues to grow exponentially. Space is becoming more congested. For example, CubeSats and other small satellites are being launched with increasing frequency, 

and several companies are now deploying mega-constellations with hundreds, or even thousands, of 

satellites. Some of these satellites incorporate the use of electric propulsion and autonomous onboard 

maneuvers with very short turnaround times, increasing the difficulty of tracking and planning for 

collision avoidance. 

It is important to recognize the prevalence of the issue. Orbital debris events and close calls are not 

rare, but they are in fact becoming more and more frequent as space becomes more congested and as 

national and international space players—who rightfully seek to leverage the high ground of space for 

commerce, science, and national prestige—continue to populate the space domain with new satellites. 

The risks are growing, and a more strategic approach to the problem is now necessary to arrest the risks 

and to assure that the domain of space remains sustainable.

NASA currently has 20 missions in low-Earth orbit, and the Agency definitely takes the risk 

seriously. But the issue is larger than NASA—it affects and is affected by all entities that conduct 

operations in space, and it endangers all of those functions on which the public has come to rely—

communications, navigation, weather prediction, to just start the list. While the ASAP is principally 

focused on the serious hazards to NASA spacecraft and astronauts, the Panel recognizes that the issue 

must be tackled on a broader front. 

The Panel was encouraged in 2018 when the National Space Council issued SPD-3, the National 

Space Traffic Management Policy, which acknowledged and addressed this issue and the need to 

improve Space Situational Awareness and Space Traffic Management. SPD-3 promoted the implementation of a number of steps to address the orbital debris risk and recommended that the Department 

of Commerce take responsibility for implementing a Civil Space Traffic Management framework. 

The Panel is dismayed that Congress and the Administration have not yet reached an agreement on 

the appropriate response to that recommendation, resulting in departments and agencies not being 

able to move forward on implementing a framework that will both materially reduce the Space Traffic 

Management risks and increase the sustainability of space as an international strategic domain.
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It is well overdue that the United States exert some effective international leadership in the safety 

of space operations and begin doing so by designating—including providing authority and resources 

to—a Lead Agency to see to the provision of timely and actionable safety data to all space operators; 

work proactively within government, with industry, and in partnership with the international community in developing standards, guidelines, best practices, and “rules of the road” for safe space operations; and support the conduct of scientific research and technology development for related areas, 

such as improved sensors, software, constellation management techniques, and methods for active 

debris management. 

 OPEN  NASA concurred on 12/17/20 with the recommendation to support and partner with the 

lead Federal agency for Space Traffic Management once one is selected. NASA is taking steps

in the interim to address the ASAP recommendation. Regarding astronaut and spacecraft safety,

through the leadership of the Office of Safety and Mission Assurance (OSMA), NASA continues investing in characterizing and managing risks to spacecraft and astronauts from MMOD

Regarding development of guidelines for Space Traffic Management, the NASA Office of Chief 

Engineer (OCE) has developed two documents in support of the ASAP recommendation. One

document serves to capture best practices for ensuring safe space operations with respect to 

collision avoidance, and the other document ensures future NASA missions continue to plan for 

and implement collision avoidance practices. Future updates will permit aligning the best practices with emerging space traffic management guidance by the selected lead agency. OSMA an

OCE are also working with the Space Technology Mission Directorate to outline a proposal for a 

Space Traffic Management-related technology roadmap, focused on gaps that are not being otherwise addressed. The ASAP will continue to review the Space Traffic Management technology

roadmap and awaits the Congressional designation a Lead Federal Agency before closing this 

recommendation

2019-02-01 Required Transition to Next Generation Extravehicular Mobility Units 

(EMUs)

Finding: The ASAP has become increasingly concerned with the risk posture that NASA has adapted 

regarding the current EMUs used in International Space Station (ISS) operations and has concluded 

that the current EMUs are now outside their design life. 

Recommendation: NASA should begin an immediate transition to a next-generation Extra-Vehicular 

Activity (EVA) suit system EMU, before the risk to EVA becomes unmanageable. 

Rationale: It is an undeniable fact that the 40-year-old EMUs used in ISS operations are reaching the 

end of their useful life. The Panel reviewed the increasing challenges of difficult upgrade efforts, loss of 

component vendors over time, lack of critical refurbishment parts, and life extension analyses that will 
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grow in uncertainty as the suit hardware continues to age. Over the years, the Panel has commented 

on the highly innovative and often heroic approach that NASA has taken to devise EMU component upgrades and suit life extensions. The Panel has also noted the small but productive steps accomplished by the development program for the next generation xEMU prototype. The current plan is to 

extend today’s EMU use to 2028; however, it is increasingly apparent that the usable life of the current 

EVA suits is limited. The Panel encourages NASA to step back from day-to-day management issues to 

view this urgent issue from a broader, more holistic outlook. The problem does not lie simply in the 

fact that the suits are old; but the fact that manufacturers of several critical suit components, including the very fabric of the suits, have now gone out of business, creates real urgency for transitioning to 

new EVA suit systems. New suits are needed not only for future space exploration, but also for its current space activities. NASA cannot maintain the necessary, ongoing low-Earth orbit operations without fully functional EVA suits..

 OPEN  NASA responded on 9/11/19, concurring with the recommendation. While NASA has presented plans for the development of the xEMU, including flying a prototype xEMU on the ISS for

testing, the xEMU development and acquisition approach is primarily focused on producing suits 

for the lunar campaign. The Panel has not received sufficient information indicating how the current approach to xEMU development and acquisition will mitigate the ongoing risks of extending

the current EMUs on ISS to 2028

2018-04-01 Required Actions for Crewed Flight Test Risk Reduction

Finding: There are serious challenges to the current launch schedules for both SpaceX and Boeing. 

For SpaceX, one challenge is the lack of final resolution of the composite overwrapped pressure vessel failures, which are generally considered to have been involved in a launch pad accident and which 

affect the total safety of the “load-and-go” launch concept. In addition to this issue, recent parachute 

performance, both during the Commercial Crew Program (CCP) qualification-testing regimen and 

during the resupply contract, indicates potential problems with parachute designs. A potential redesign, which may be required, would drive a requirement for additional qualification and certification 

testing. The Boeing program also holds key risk items, some of which have emerged during the qualification test program; specifically: parachutes, launch abort engine hot fire testing, and pyrotechnic 

separation bolt initiator device qualification failures. The burn-down curve of certification products 

remains fairly steep for verification and validation, and much work is ahead. Schedule pressures and 

the desire to launch pose a potential for the uncrewed test flights to occur without all the critical content to fulfill the role of risk reduction for crewed flight.
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Recommendation: NASA should confirm and then clearly communicate the required content and 

configuration for the upcoming CCP test flights—Demo-1 and Orbital Flight Test (OFT)—specifically, those items that must be successfully demonstrated prior to the first crewed flights.

Rationale: Despite a desire to launch the uncrewed test flights (Demo-1 and OFT) as soon as feasible, 

it is important to keep in mind that the primary purpose of those flights is to fly the vehicles in a configuration as close as possible to the first crewed flights in order to reduce risk. If content important to 

that purpose is not flown in a test that essentially duplicates the conditions of the first crewed flights, 

uncertainty is increased, and safety could be compromised.

 OPEN  NASA originally responded on 3/29/19, concurring with the recommendation. NASA continues to work with the commercial providers to obtain valuable data from both crewed and

uncrewed test flights in order to minimize risk and correct any emerging issues. The results from

the series of reviews for each flight will culminate in a Certificate of Flight Readiness, asserting that the commercial provider has completed all work associated with meeting the applicable 

requirements, standards (including alternate standards), and hazard reports. The final certification

work for SpaceX has been completed and they have moved on to operational flights, just launching Crew-1 and Crew-2. The certification work continues with the Boeing system and should

undergo the same rigorous process of reviewing the results of every flight to assure any issues are 

worked or corrected. Work will be ongoing into 2022 and beyon

2018-04-02 Action to Ensure U.S. Access to the International Space Station 

Given Commercial Crew Program Schedule Risk

Finding: As outlined in the Finding for Recommendation 2018-04-01, serious technical difficulties and challenges pose considerable risk to both providers’ schedules for crew transportation to the 

International Space Station (ISS) in calendar year 2019. Currently, there are no Soyuz seats available 

for U.S. crew after 2019.

Recommendation: Due to the potential for delays in the schedule for the first Commercial Crew 

Program (CCP) flights with crew, senior NASA leadership should work with the Administration and 

Congress to guarantee continuing access to ISS for U.S. crew members until such time that U.S. capability to deliver crew to the ISS is established.

Rationale: Without CCP flights in 2019, the U.S. will have no other means of access to the ISS unless 

other options are identified and approved, or existing constraints are waived. Although they may not 

be needed, having back-up plans in place for such contingencies could be extremely important if the 

CCP flights are significantly delayed.
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 OPEN  NASA responded on 3/29/19, concurring with the recommendation. NASA is developing options to protect the presence of American crew on the ISS to support the U.S. On-Orb

Segment. During the ASAP’s 2020 Second Quarterly meeting, the Panel advised NASA to broaden

its approach to this issue and resolve this recurring risk as part of normal practice and not on an 

increment-by-increment basis. Specifically, consider sustainable solutions in the event of continuing

operations with reduced crew capacity that ensure that the critical crew skill sets are on board at all 

times. For example, manifesting every crew rotation flight, on either U.S. or Russian spacecraft, 

have at least one U.S. and one Russian crewmember on board to facilitate this kind of “insuranc

2016-04-01 Asset Protection—Security Clearance Policy

Finding: NASA is taking a holistic approach to asset protection, linking space asset protection, 

cybersecurity, and critical infrastructure on the ground. The identification of James Leatherwood as 

Principal Advisor to the Associate Administrator and establishing an Enterprise Protection Program 

(EPP) modeled after the Technical Authorities is a positive step. The Panel was gratified to see that 

NASA is taking a holistic approach and starting down the path of putting in place the management 

policies and practices to have an effective EPP. While there are many challenges ahead, one of the big 

challenges to an effective program is having appropriate clearances for the appropriate people in the 

Agency who make the decisions to protect assets from threats. Currently, there are too many cases 

where security clearances are lacking. NASA has put in place a system to work around these difficulties, but it is not optimum.

Recommendation: NASA should make it a matter of policy that priority is given to obtaining the 

appropriate level of security clearance for all personnel essential to implementing the EPP, including 

the appropriate program managers.

Rationale: The appropriate people in the Agency need to have to have a level of clearance necessary to 

understand the threat, make the proper decisions, and allocate the proper resources. When a new program manager is coming online, if he or she does not have the appropriate security clearance already, 

submitting the necessary paperwork may not be high on the new manager’s list of tasks. NASA needs 

a policy to put a high priority on the submission of appropriate clearance paperwork. 

 OPEN  NASA responded on 1/17/17, concurring with the recommendation. In 2019, NASA established clearance requirements within the governance management system of the EPP and

reviewed positions, descriptions, and compliances. In early 2020, the Panel requested a summary

of the outcomes of this advertised process—specifically, a NASA-wide list of program managers’ 

job descriptions and their current security clearance requirements/status. The Panel will then be

able to ascertain the effectiveness of the advertised process to assure that security clearances are 

appropriately distributed. It is hoped that the outcomes of the 2019 reviews generated appropriately adjusted security clearance requirements for key personnel who have technical authorities
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and responsibilities, and are accountable for implementing EPP policies, directives, and threat 

information within their programs

2015-05-02 Human Space Flight Mishap

Finding: The CCP is now developing a formal plan for how it will respond in the event of a major 

malfunction or mishap. In addition to optimizing what can be learned by proper investigation of malfunctions or mishaps, this plan must comply with specific language in the NASA Authorization Act 

of 2005 concerning Human Spaceflight Independent Investigations. NASA has tentatively identified 

the entities that would investigate various types of mishaps during the five mission phases. Under the 

current Authorization language, a Presidential Commission would be required in all cases involving 

loss of the flight crew as well as in all cases involving loss of the vehicle, even if the flight crew is not 

injured. Use of a Presidential Commission in the latter cases appears excessive.

Recommendation: The Authorization language should be reviewed with today’s systems in mind. 

Also, more details appear appropriate for the NASA implementation document. These details would 

include the level of vehicle damage requiring investigation, the temporal issues of when mission phases 

begin and end, and NASA’s oversight role in mishap investigations conducted by its providers, as well 

as when the need for outside oversight is required. The mishap response procedures should be thought 

through, documented, and in place well before any actual flights.

Rationale: The requirement for a Presidential Commission was logical for the International Space 

Station or Space Shuttle missions because they were reusable national assets. It would, however, appear 

excessive in some cases for commercially provided vehicles or other vehicles not planned for reuse. One 

example would be the sinking of a non-reusable vehicle after the flight crew had been safely recovered 

and were on their way home.

 OPEN  NASA originally responded on 4/30/16, concurring with the recommendation. The response

stated that NASA was reaching out to the Federal Aviation Administration and the National 

Transportation Safety Board to jointly develop viable options to revise the Authorization language 

with today’s systems in mind. NASA provided a follow-up response on 3/20/17 in which they provided the results of NASA’s assessment of strategy option in the event of a major malfunction or

mishap in the Commercial Crew Program. The ASAP provided a written response on 9/8/17, followed by subsequent discussions during which the ASAP provided alternate solutions to which

NASA provided a third response on 3/15/18. NASA and the Congress are still working to establish

a satisfactory process to address the concerns previously articulated. The ASAP believes action

is increasingly essential and urgent as NASA has already begun launching astronauts on commercially provided vehicles, and the future Artemis missions will be even more complex in their 

involvement of commercial providers and international partners
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APPENDIX B

Closure Rationale for Recommendations Closed in 2021

2021-01-01 Design a Top-Level Plan for the Size and Composition of the NASA 

Workforce and Infrastructure

Finding: NASA has stated that the size and composition of the NASA workforce should be shaped 

by strategic guidance, rather than by independent hiring plans developed at the Center and organizational level. However, based on the information the Panel has received to date, it appears that key 

decisions related to workforce needs are being made tactically by individual Centers, rather than in 

collaboration with Headquarters, or in response to top-down guidance. 

The NASA Human Capital Office has also developed a number of principles intended to guide its 

workforce management efforts, such as “NASA’s total workforce is agile and mission-driven, not supply-driven in all workforce segments.” Although that may be the ultimate goal, it does not appear to 

be an accurate assessment of the current situation, and the Panel is not aware of a coordinated strategy 

to achieve such a state of affairs. 

Depending on how NASA answers the questions regarding its role and workforce, they have an 

opportunity to align their infrastructure to their long-term strategy. That is, by taking a top-down 

approach to align all Centers to Agency priorities, they should identify and close facilities that are not 

critical to Agency programs. This will contribute directly to reducing fixed costs and freeing resources 

for NASA’s programs.

Recommendation: NASA should develop a top-level plan for the size and composition of its workforce and its infrastructure that takes into account its aspirations for future missions, innovation and 

technology development, and potential partnerships with industry, academia, and the international 

community. The plan should be developed in coordination with the Centers and should clearly articulate roles and responsibilities for maintaining the necessary expertise and experience. The plan should 

also be communicated with key stakeholders and updated on a regular basis.
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Rationale: The existence of a skilled and experienced workforce has always been critical for NASA to 

safely accomplish its mission. Because of rapid changes in technology and an increased reliance on 

commercial and international partners, it is more important than ever for NASA to think strategically 

about its future workforce and infrastructure needs. Such an effort will be challenging, and it will certainly take time to complete; however, because it will likely have significant and immediate benefits, it 

should be initiated as soon as possible. 

NASA’s Response: NASA responded on 6/14/21 by concurring with the recommendation to develop 

a top-level plan for workforce and infrastructure. NASA stated that such plans are currently underway with a progression of steps. These plans are deleted for workforce, with the Office of Chief 

Human Capital Officer leading the development; and for infrastructure, with the Office of Strategic 

Infrastructure leading the development. NASA agrees with the ASAP’s opinion that “such an effort will 

be challenging, and it will certainly take time to complete.” Given the scope of the effort, this NASA 

response did not commit to a delivery date, however, leadership was amenable to providing periodic 

briefings to the ASAP to assess progress. This recommendation is superseded by Recommendation 

2021-05-01.

2018-02-01 NASA Safety Assurance Process Scope and Quality (2017-02-01 

REVISED) 

Finding: In visiting the Centers and the NASA Safety Center (NSC), the Panel found some deficiencies in the audit system—such as system safety—where it became apparent that the workforce was not 

adhering to policies and procedures, or that policies and procedures were not well understood. While 

in some cases there was integrity and audit processes, in other areas the NSC did not appear to be 

auditing at all or they audited infrequently.

The Panel is comfortable that the Office of Safety and Mission Assurance (OSMA) has established, 

prioritized, and implemented a schedule and periodicity cycle for Center-level safety audits. However, 

the Panel wants assurance that the OSMA has a mechanism in place to verify that the NASA safety 

policies, processes, and procedures are being followed to ensure effective employee safety, system safety, 

and program safety. Effective safety assurance involves in-depth assessments of safety culture and firsthand observation of safety processes, in addition to the detailed programmatic compliance checks.

Recommendation (revised): NASA’s OSMA should have a coordinated, in-depth system of safety 

assurance tools and processes to verify effective programmatic safety compliance, system safety practices, safety process function, safety culture, and overall safety posture at all levels of the organization.

Rationale: The Panel believes this would be an opportunity to take a fresh look across the Agency at 

what is being done to achieve the goal and measure progress. The Panel emphasized that “effective” 
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means is not just a paper drill (a checklist)—it should be what is actually being done. The Panel wants 

positive confirmation that the OSMA not only has a policy, but that the policy is embraced across the 

Agency. The Panel is not asking the OSMA to create something new, but to ensure that what they have 

is modified or updated to (1) include system safety, (2) verify that the policies and practices are being 

followed on a daily basis, and (3) identify any “gaps” that are not being covered.

NASA’s Response: NASA initially responded on 8/10/18, concurring with the recommendation, 

which is a revision of ASAP Recommendation 2017-02-01. NASA provided a summary of current 

and future activities, including deep-dives at selected NASA Centers and documentation of its findings and recommendations for an ongoing performance-based safety and mission success audit process in a State of Capability report. The ASAP reviewed the report and had planned to attend an audit 

in 2020 to confirm progress. However, with the COVID-19 pandemic, the scheduled audits had to 

be postponed. The ASAP was able to attend a virtual audit in 2021 and feels the intent of this recommendation has been met.

2017-01-01 Practice of System Engineering and Integration Principles by 

Commercial Crew Providers for Transportation Services to the ISS

Finding: The investigations into two recent mishaps on commercial launch vehicles have concluded 

that the mishaps were unrelated because the immediate (or proximate) causes of the mishaps were different. However, in the opinion of the Panel, the underlying root causes of both mishaps can be traced 

to escapes in the System Engineering and Integration (SE&I) process and controls involving one or 

more of the following areas: design, analysis, manufacturing, quality control, qualification, and operations (including operational tests).

Recommendation: The Panel recommends that NASA require the Commercial Crew providers to produce verifiable evidence of the practice of rigorous, disciplined, and sustained SE&I principles in support of the NASA certification and operation of commercial crew transportation services to the ISS.

Rationale: Rigorous and disciplined SE&I processes and controls are essential elements of any engineering effort. When dealing with complex systems for human space travel, where inherent risks must 

be managed to an acceptable level, the emphasis on SE&I and cross-discipline engineering is even 

more critical. No amount of NASA oversight or insight into the performance of the commercial providers can compensate for a lack of rigor in the providers’ SE&I processes and controls. On a regular 

basis, the commercial providers make numerous important decisions that do not rise to the level of 

NASA oversight. Their detailed knowledge of the system design, qualification, and performance generally exceeds that of the NASA engineers who provide insight and oversight. Thus, the responsibility 
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for producing a system that provides an acceptable level of risk for NASA missions to the ISS rests 

heavily on the commercial providers and their SE&I processes and controls.

Finally, it is important for the provider to not only furnish evidence that rigorous, disciplined, and 

sustainable SE&I processes and controls are in place, but they should also be shown to be effective 

over time. This is a foundation for all other certification activities. 

NASA Response: NASA initially responded on 5/22/17, concurring with the recommendation. 

NASA stated that the Commercial Crew providers are responsible for ensuring cost-effective system 

design, realization, operation, and technical management of the systems they are developing to meet a 

fixed-price contract. Through contract requirements, deliverables, and insight, the Commercial Crew 

Program is able to verify and/or validate that SE&I principles are followed to assure the proper management of risks, requirements, interfaces, configuration, and technical data throughout the system 

life cycle. In addition, the Boeing Orbital Flight Test (OFT) mishap of December 2019 offered additional opportunity for NASA to hone its oversight of SE&I principles.

The ASAP continued to monitor the SE&I practices throughout the development and certification process, and how SE&I “lessons learned” from the Commercial Crew Program promulgate 

through other human spaceflight programs. The intent of the recommendation has been met.
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APPENDIX C 

ASAP Members and Staff

Aerospace Safety Advisory Panel Members

Dr. Patricia A. Sanders

f Chair, Aerospace Safety Advisory Panel

f Independent Aerospace Consultant

f Former Executive Director of the Missile Defense Agency (MDA)

f Former Director, Test, Systems Engineering, and Evaluation, Office of the 

Secretary of Defense

f Former Director of Analysis for the U.S. Space Command

Dr. Patricia Sanders is now an independent aerospace consultant after having been a Senior Executive 

with the Department of Defense (DoD) and retiring from the Federal Government after 34 years of 

service with experience in the management of complex technical programs, leadership of large and 

diverse organizations, and development and execution of policy at the DOD level.

Dr. Sanders retired from Government service in 2008 as the Executive Director of the Missile 

Defense Agency (MDA). She was the senior civilian in the Agency responsible for its management 

and operations, safety and quality control, strategic planning, legislative affairs, external communication, and all issues related to worldwide personnel administration and development. Previously, she 

had been the System Executive Officer and Deputy Director for Integration of MDA, managing program content, schedule, cost, and technical performance for the Agency’s $9 billion per year program 

of work.

After teaching for Boise State University and the University of Utah, Dr. Sanders began her 

national security career with the U.S. Army in Germany in 1974. She progressed through a number of 

challenging positions, including management of several Defense acquisition programs; positions with 

the Air Force Operational Test Center in space system and aircraft avionics testing; Chief Scientist for 
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the Command, Control, and Communications Countermeasures Joint Test Force; and Director of 

Analysis for the U.S. Space Command.

In 1989, Dr. Sanders moved to the National Capital Area to assume the first of a number of staff 

positions within the Office of the Secretary of Defense, culminating with service as the Director of 

Test, Systems Engineering, and Evaluation. She joined the missile defense community in 1998 and 

participated in the establishment of the MDA, was responsible for creating its robust test organization, 

initiated the Sensors Directorate, and accomplished pioneering work in managing integration of the 

Ballistic Missile Defense System.

Dr. Sanders has actively supported professional, academic, and civic organizations, serving on 

numerous executive boards. She is a Fellow of the American Institute of Aeronautics and Astronautics 

(AIAA) and has received three Presidential Rank Awards for executive achievements. She was awarded 

the Allen R. Matthews Award for significant accomplishments in test and evaluation and the AIAA 

DeFlorez Award for Modeling and Simulation, which recognizes achievements in its aerospace 

applications.

Mr. David B. West, CSP, ASP, PE, CHMM

f Examinations Director, Board of Certified Safety Professionals (BCSP)

f Executive Vice President, International System Safety Society (ISSS)

f Former Vice President and Deputy Operation Manager, Science Applications 

International Corporation (SAIC)

f Former Chair, G-48 System Safety Committee of SAE International

f Former Member and Treasurer, BCSP Board of Directors

Mr. David B. West is the Examinations Director at the Board of Certified Safety Professionals (BCSP). 

He is responsible for BCSP activities involving the development, validation, maintenance, and 

administration of examinations for BCSP certification candidates in the safety, health, and environment field. He previously served as an engineer and system safety subject matter expert for Science 

Applications International Corporation (SAIC) in positions of increasing responsibility, including 

vice president, deputy operation manager, and operation-level chief technology officer. In more than 

28 years with SAIC, Mr. West’s work helped ensure the safety of a variety of systems and programs of 

national importance, including U.S. Army manned and unmanned fixed-wing aircraft and helicopters, military ground vehicle immersive training systems, rocket-launching weapon systems, precision 

targeting systems, chemical weapons destruction facilities, uranium enrichment and other nuclear 

operations, super-conducting magnetic energy storage technology, petroleum refining and chemical 

manufacturing, the Space Station Freedom Program, Space Shuttle microgravity experiments, and the 

Space Shuttle range safety system. In more recent years, Mr. West learned and applied the concepts of 

software system safety on various projects.
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For many years, Mr. West actively led or supported standards-developing activities for system 

safety and other specialty engineering disciplines. From 2010 to 2019, Mr. West chaired the G-48 

System Safety Committee, currently under SAE International. He was one of the authors of the 

G-48 Committee’s “Standard Best Practices for System Safety Program Development and Execution,” 

GEIA-STD-0010, and was the sponsor of its first major revision. From 2017 through 2018, Mr. West 

served as the Vice Chair of SAE International’s Systems Management Council. Mr. West served on 

the BCSP Board of Directors from 2008 to 2013 and was the Board’s Treasurer from 2012 to 2013.

Mr. West is a Fellow Member of the International System Safety Society (ISSS) and was awarded 

its highest honor, the Professional Development Award, in 2013. He was also named the ISSS 

Manager of the Year in 2010. Mr. West was active in Toastmasters International from 2009 through 

2017 and has been an invited speaker on system safety topics at several national and international 

events, including the 1st International Helicopter Safety Symposium in 2005, the FAA 9th Annual 

Commercial Space Transportation Conference in 2006, the Australian System Safety Conference in 

2013, and numerous International System Safety Conferences since 2001.

Mr. West earned a B.S. in nuclear engineering from the University of Cincinnati. He holds the 

Certified Safety Professional (CSP), Associate Safety Professional (ASP), and Certified Hazardous 

Materials Manager (CHMM) credentials, and he is a registered Professional Engineer (PE). Mr. West 

enjoys astronomy, bicycling, and traveling.

Dr. Richard S. Williams, MD, MPH, FACS

f Director, Three Rivers Health District, Virginia Department of Health

f Director, Eastern Shore Health District, Virginia Department of Health

f Senior Aviation Medical Examiner, Federal Aviation Administration

f Former NASA Chief Health and Medical Officer 

Dr. Richard S. Williams is a surgeon and aerospace medicine physician who currently serves as 

Director of the Three Rivers and the Eastern Shore Health Districts of the Virginia Department of 

Health. He leads 12 public health departments serving a 2,500-square-mile rural area in Virginia’s 

Middle Peninsula, Northern Neck, and Eastern Shore, responsible for public health care and environmental health support to a population of about 183,000. He is also a Federal Aviation Administration 

Senior Aviation Medical Examiner, providing aeromedical consultation services for all classes of airmen. Previously, he served as NASA’s Chief Health and Medical Officer. He spent 27 years in the U.S. 

Air Force (USAF) as a general surgeon, flight surgeon, and medical manager and leader, domestically 

and in contingency operations abroad.

Dr. Williams reported to NASA Headquarters as an Air Force Colonel in 1998. He served as 

Director of the Office of Health Affairs and entered the Senior Executive Service as NASA’s Chief 

Health and Medical Officer in 2002. He led NASA’s health care team through the construction and 
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initial operation of the International Space Station and the final years of the Space Shuttle Program. 

His responsibilities included leadership, policy, oversight and advocacy for astronaut health care, 

NASA employee health care, protection of research subjects, and bioethics. During his 15-year tenure, Dr. Williams led efforts to secure legislative authority for beyond-career astronaut health care, 

implemented Health and Medical Technical Authority, produced policies on ethics-based risk assessment for astronaut health and medical exposures during space flight missions, and fostered cooperative efforts between NASA’s Human Research Program and health care system to better understand 

space flight–related health risks and mitigations.

Dr. Williams received a B.S. degree from the College of William and Mary in 1975, as well as an 

MD degree in 1979 and an MPH degree in 1996, both from Virginia Commonwealth University. He 

completed general surgery residency at Wright State University in 1984 and aerospace medicine/occupational health residency at the USAF School of Aerospace Medicine in 1998. He is a Fellow of the 

American College of Surgeons and maintains certification by the American Board of Preventive 

Medicine in Aerospace Medicine. His awards and decorations include the Bronze Star medal, the 

Meritorious Service Medal, the John R. Tamisea Memorial Award, NASA’s Space Flight Awareness 

Award for Safety, the Melbourne C. Boynton Award, the Senior Executive Service Presidential Rank 

Award, the W. Randolph Lovelace Award, the Forrest M. and Pamela Bird Award, the NASA 

Exceptional Leadership Medal, and the NASA Distinguished Service Medal. He has contributed to 

and published numerous articles and book chapters in the medical literature.

Lieutenant General Susan J. Helms, USAF (Ret.)

f Independent Consultant and Principal of Orbital Visions, LLC

f Former Commander, 14th Air Force, Air Force Space Command

f Former Commander, Joint Functional Component Command for Space, U.S. 

Strategic Command

f Former NASA Astronaut 

Lieutenant General Susan J. Helms, USAF (Ret.), is currently an independent consultant and the 

Principal of Orbital Visions, LLC. She is also on a number of boards, including the Board of Trustees 

for The Aerospace Corporation.

General Helms has almost 36 years of military service in the U.S. Air Force. In her last assignment, she was Commander, 14th Air Force (Air Forces Strategic), Air Force Space Command; 

and Commander, Joint Functional Component Command for Space, U.S. Strategic Command, 

Vandenberg Air Force Base, CA. As the leader of the U.S. Air Force’s operational space component, General Helms led more than 20,500 personnel responsible for providing missile warning, 

space superiority, space situational awareness, satellite operations, space launch, and range operations. As Commander, Joint Functional Component Command for Space, she directed all assigned 
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and attached space forces providing tailored, responsive, local, and global space effects in support of 

national and combatant commander objectives.

General Helms was commissioned from the U.S. Air Force Academy in 1980 and is a distinguished graduate of the USAF Test Pilot School (Flight Test Engineer Course). She has served as an 

F-15 and F-16 weapons separation engineer and as a flight test engineer for the CF-18. She has also 

commanded the 45th Space Wing, Patrick Air Force Base, Cape Canaveral, FL, and served as the J5, 

U.S. Strategic Command.

Selected by NASA in January 1990, General Helms became an astronaut in July 1991. On January 

13, 1993, then an Air Force Major and a member of the Space Shuttle Endeavour crew, she became 

the first U.S. military woman in space. She flew on STS-54 (1993), STS-64 (1994), STS-78 (1996), 

and STS-101 (2000), and she served aboard the ISS as a member of the Expedition-2 crew (2001). A 

veteran of five space flights, General Helms has logged 211 days in space, including a spacewalk of 8 

hours and 56 minutes, a world record.

Mr. William P. Bray

f Vice President, Strategic Business Operations, Frontier Technology Incorporated

f Former Deputy Assistant Secretary of the Navy for Research, Development, 

Test and Evaluation 

f Former Executive Director, Navy Program Executive Office (PEO) for 

Integrated Warfare Systems (IWS)

f Former, Director for Integrated Nuclear Weapons Safety and Security at Navy 

Strategic Systems Program, Direct Reporting Program Management (DRPM) 

Office

Mr. Bray currently serves as the Vice President for Strategic Business Operations at Frontier 

Technology Incorporated (FTI). In that role, he leads FTI efforts for Strategy Development and 

Business Integration. 

Mr. Bray retired after 36 years of government service in September 2020, the last 14 years serving in the Senior Executive Service Corps. His last assignment was as the Deputy Assistant Secretary 

of the Navy for Research, Development, Test and Evaluation (DASN (RDT&E)) under the Assistant 

Secretary of the Navy for Research, Development and Acquisition (ASN RD&A). In that role, Mr. 

Bray was responsible for executive oversight of all matters related to Naval RDT&E Budget Activities, 

Science and Engineering, Advanced Research and Development, Prototyping and Experimentation, 

and Test and Evaluation. In addition, he was responsible for oversight and stewardship of the 

Department of Navy Research and Development Establishment which included Naval Laboratories, 

Warfare Centers, and Navy University Affiliated Research Centers.

Prior to the DASN RDT&E position, Mr. Bray was the Executive Director for PEO IWS where 

he directed the acquisition and Fleet support of the Surface Navy’s combat systems, weapons, radars, 
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and related international and foreign military sales programs. Other leadership roles within the Navy 

included the Director, Integrated Nuclear Weapons Safety and Security at the Navy Strategic Systems 

Programs Office, and Major Program Manager (MPM) for Surface Navy Combat Systems. Mr. Bray 

started his career at the Naval Surface Warfare Center, Corona Division, California in December 1984.

Mr. Bray is a graduate from The Pennsylvania State University in 1984 with a Bachelor of Science 

degree in Petroleum and Natural Gas Engineering, and also earned a Master of Science in Systems 

Management from the University of Southern California. He was Defense Acquisition Workforce 

Improvement Act (DAWIA) Level III certified in Program Management, Engineering, and Test and 

Evaluation. During his government career, he received a Meritorious Executive Presidential Rank 

Award in 2018, the Navy Distinguished Civilian Service Award in 2017 and 2020, and the Navy 

Superior Civilian Service Award in 2013.

Dr. George C. Nield

f Independent Aerospace Industry Consultant

f Former Associate Administrator for Commercial Space Transportation, Federal 

Aviation Administration

f Former Manager of the Flight Integration Office at the NASA Johnson Space 

Center

f Flight Test Engineering Graduate of the USAF Test Pilot School

Dr. George C. Nield, currently an Independent Aerospace Industry Consultant, was formerly the 

Associate Administrator for Commercial Space Transportation at the Federal Aviation Administration 

(FAA). Under his leadership, the office had the mission to ensure public safety during commercial 

launch and reentry activities, as well as to encourage, facilitate, and promote commercial space transportation. Dr. Nield has over 35 years of aerospace experience with the Air Force, at NASA, and in 

private industry.

Prior to joining the FAA, Dr. Nield was a Senior Scientist for the Advanced Programs Group at 

Orbital Sciences Corporation, where he worked on the Space Transportation Architecture Study, the 

2nd Generation Reusable Launch Vehicle Program, and the Orbital Space Plane. Previously, he served 

as Manager of the Flight Integration Office for the Space Shuttle Program at the NASA Johnson Space 

Center, and he later worked on both the Shuttle/Mir Program and the International Space Station 

Program. While on active duty with the Air Force, he was an assistant professor and research director at the USAF Academy. As a flight test engineer for the Air Force Flight Test Center at Edwards 

Air Force Base, he supported the A-7 DIGITAC program, the YC-14 Advanced Medium STOL 

Transport, and the Space Shuttle Approach and Landing Tests. He also served as an astronautical engineer with the Space and Missile Systems Organization, identifying technology requirements for military space vehicles.
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A graduate of the USAF Academy, he holds an M.S. and Ph.D. in Aeronautics and Astronautics 

from Stanford University and an MBA from George Washington University. He is also a flight test 

engineering graduate of the USAF Test Pilot School. Dr. Nield is a registered Professional Engineer 

and a Fellow of the American Institute of Aeronautics and Astronautics.

Dr. Sandra H. Magnus

f Principal, AstroPlanetview, LLC

f Former Deputy Director-Engineering in the Office of the Undersecretary for 

Research and Engineering, Department of Defense (DOD) 

f Former Executive Director of the American Institute of Aeronautics and 

Astronautics (AIAA)

f Former NASA Astronaut

Dr. Sandra H. “Sandy” Magnus is currently the Principal at AstroPlanetview, LLC and a part time 

Professor of the Practice at the Georgia Institute of Technology. Before joining Georgia Tech she was 

the Deputy Director of Engineering in the Office of the Secretary of Defense for the Undersecretary 

of Research and Engineering. In that role she served as the “Chief Engineer” for the DoD establishing engineering policy, propagating best practices and working to connect the engineering community across the department. In addition, she is the former Executive Director of the American Institute 

of Aeronautics and Astronautics (AIAA), the world’s largest technical society dedicated to the global 

aerospace profession. Prior to leading AIAA, Dr. Magnus was a member of the NASA Astronaut 

Corps for 16 years.

Born and raised in Belleville, Illinois, Dr. Magnus attended the Missouri University of Science 

and Technology, graduating in 1986 with a degree in physics and earning a master’s degree in electrical engineering in 1990. She received a Ph.D. from the School of Materials Science and Engineering 

at Georgia Tech in 1996.

Selected to the NASA Astronaut Corps in April, 1996, Dr. Magnus flew in space on the STS112 shuttle mission in 2002, and on the final shuttle flight, STS-135, in 2011. In addition, she flew 

to the International Space Station on STS-126 in November 2008, served as flight engineer and science officer on Expedition 18, and returned home on STS-119 after four and a half months on 

board. Following her assignment on Station, she served at NASA Headquarters in the Exploration 

Systems Mission Directorate. Her last duty at NASA, after STS-135, was as the deputy chief of the 

Astronaut Office.

While at NASA, Dr. Magnus worked extensively with the international community, including the 

European Space Agency (ESA) and the Japan Aerospace Exploration Agency (JAXA), as well as with 

Brazil on facility-type payloads. She also spent time in Russia developing and integrating operational 

products and procedures for the International Space Station.
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Before joining NASA, Dr. Magnus worked for McDonnell Douglas Aircraft Company from 1986 

to 1991, as a stealth engineer. While at McDonnell Douglas, she worked on internal research and 

development and on the Navy’s A-12 Attack Aircraft program, studying the effectiveness of radar signature reduction techniques.

Dr. Magnus has received numerous awards, including the NASA Space Flight Medal, the NASA 

Distinguished Service Medal, the NASA Exceptional Service Medal, Office or the Secretary of Defense 

Medal for Exceptional Public Service and the 40 at 40 Award (given to former collegiate women athletes to recognize the impact of Title IX). 

Mr. Paul Sean Hill

f Independent Consultant, Author, Speaker, and Principal of Atlas Executive 

Consultant, LLC 

f Former Director of Mission Operations, NASA Johnson Space Center

f Former Shuttle and ISS Flight Director

Paul Sean Hill is an author and speaker focused on the leadership principles that are critical in creating 

and leading high-performing teams in any industry. During his 25 years at NASA, Paul first developed 

Space Station construction techniques and then led flights from Mission Control as a Space Shuttle 

and International Space Station Flight Director. He supported 24 missions as a Flight Director from 

1996 through 2005, culminating as the Lead Shuttle Flight Director for the return to flight on STS114 after the Columbia accident.

After a series of senior leadership positions, Paul served as the Director of Mission Operations for 

human space flight from 2007 through 2014, responsible for all aspects of mission planning, flight 

controller and astronaut training, and Mission Control. He is credited with revolutionizing the leadership culture, dramatically reducing costs, and increasing capability, all while still conducting missions in space.

Before his work with NASA, Paul served in the U.S. Air Force in military satellite operations. 

He earned his Bachelor’s and Master of Science degrees in aerospace engineering from Texas A&M 

University in 1984 and 1985, respectively, and was a member of the Corps of Cadets. 

His professional awards include the Presidential Rank Award of Meritorious Executive, two NASA 

Outstanding Leadership Medals, the NASA Distinguished Service Medal, the NASA Exceptional 

Service Medal, the Rotary National Award for Space Achievement—Stellar Award, and selection as 

one of the Marshall Goldsmith 100 Coaches.
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Dr. Amy K. Donahue

f Provost and Chief Academic Officer

f United States Coast Guard Academy Professor emeritus of Public Policy

f University of Connecticut Former Senior Advisor to the Administrator for 

Homeland Security at NASA

Dr. Amy Donahue is Provost and Chief Academic Officer at the United States Coast Guard Academy. 

Dr. Donahue provides primary leadership and direction for all academic activities and faculty affairs 

at the Academy. 

Dr. Donahue is professor emeritus of public policy at the University of Connecticut (UConn) 

where her research has focused on executive leadership, homeland security, and disaster preparedness. 

She was principal investigator on research funded by the Department of Homeland Security as part 

of the Center of Excellence for the Study of Natural Disasters, Coastal Infrastructure and Emergency 

Management. 

From 2011 to 2018, Dr. Donahue served as UConn’s Vice Provost for Academic Operations and 

Chief of Staff to the Provost. Prior to that, Dr. Donahue headed UConn’s Department of Public Policy. 

Previously she advised the Chancellor of Louisiana State University immediately following Hurricane 

Katrina and was the founding director of LSU’s Stephenson Disaster Management Institute. 

From 2002 to 2004, Dr. Donahue was Senior Advisor to the Administrator for Homeland Security 

at NASA and, as the agency’s liaison to the Department of Homeland Security and the Homeland 

Security Council, was responsible for identifying opportunities for NASA to contribute to homeland 

security efforts across government. In 2003, she had a major leadership role in the field response to the 

Columbia mishap. From 2004 to 2007, Dr. Donahue served on the Aerospace Safety Advisory Panel 

and was recently reappointed to the Panel.

As the Distinguished Military Graduate of Princeton’s Reserve Officer Training Corps in 1989, 

she began her U.S. Army career in the 6th Infantry Division at Fort Wainwright, Alaska. Her military assignments included serving as Officer in Charge of a Forward Surgical Team, as the Training 

and Operations Officer (S3) for the 706th Main Support Battalion, and as Chief of Mobilization, 

Education, Training, and Security for Bassett Army Hospital. She moved on to manage a 911 communications center, and to volunteer part-time as a firefighter and medic in Fairbanks, Alaska and upstate 

New York.

Dr. Donahue holds her Ph.D. in Public Administration and her M.P.A. from the Maxwell School 

of Citizenship and Public Affairs at Syracuse University. She graduated magna cum laude with a B.A. 

in Geological and Geophysical Sciences from Princeton University. She was elected a fellow of the 

National Academy of Public Administration in 2011. She is certified as a Wilderness Emergency 

Medical Technician.
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Aerospace Safety Advisory Panel Staff Members

Ms. Carol Hamilton, ASAP Executive Director

Ms. Carol Hamilton, Executive Director of the ASAP since 2015, has specialized in 

system safety engineering for more than 25 years. Her career also includes experience in systems engineering, systems verification, and system test engineering for 

both NASA space systems and the Department of Defense systems. During her time 

at Goddard Space Flight Center (GSFC) from 1991 to 2015, Ms. Hamilton contributed to more than 15 space flight missions, serving as a Senior System Safety 

Engineer for Hernandez Engineering for 8 crewed Space Shuttle missions and later 

as the Project Safety Manager for 14 uncrewed space missions. During her NASA 

career, she has been an instructor for the NASA Safety Training Center and has 

served on a number of NASA mishap investigation boards.

Ms. Lisa Hackley, ASAP Administrative Officer

Ms. Lisa Hackley has worked at NASA Headquarters for over 29 years providing 

administrative support for numerous mission directorates and divisions, including 

the Office of Space Flight (now Human Operations and Exploration), the Office of 

Life and Microgravity Science and Applications (now Space Life and Physical 

Sciences), the Office of Biological and Physical Research and the Office of 

International and Interagency Relations (OIIR). Prior to joining the Advisory 

Committee Management Division (ACMD) as the ASAP Administrative Officer in 

May 2019, Ms. Hackley worked in OIIR’s Export Control and Interagency Liaison 

division for 15 years, including a voluntary secondment to the Federal Emergency 

Management Agency (FEMA) in late 2017 to assist with the hurricane relief efforts.

Ms. Kerry Leeman, ASAP Annual Report Editor

Ms. Kerry Leeman received B.A. degrees from the University of Houston in philosophy and technical writing. With over two decades of experience as a technical 

writing professional spanning the aviation, aerospace, petrochemical, and biomedical industries, she joined the ASAP as a technical report writer in 2019. Her prior 

experience with NASA includes technical writing and editing for the Constellation 

Space Suit Program and demonstrating the extravehicular mobility unit spacesuit to 

Houston-area students. She is currently an information security technical writer for 

the Texas Department of Transportation in Austin, Texas.
...AND ON TO MARS

AEROSPACE 

SAFETY 

ADVISORY 

PANEL

Dr. Patricia A. Sanders, Cha

Mr. William P. Br

Dr. Amy K. Donah

Lieutenant General Susan J. Helms, USAF (Ret

Mr. Paul S. Hi

Dr. Sandra H. Magn

Dr. George C. Nie

Mr. David B. We

Dr. Richard S. Williams, 

NP-2021-12-3018-HQ