In a sobering report, NASA’s Aerospace Safety Advisory Panel (ASAP) warned that a combination of funding shortfalls and programmatic decisions have led to an “unacknowledged accretion of risk” that threaten the agency’s Commercial Crew and deep-space human exploration programs.

“As we noted in our 2014 Annual Report and continue to assert this year, NASA’s budget is insufficient to deliver all current undertakings with acceptable programmatic risk,” ASAP stated in its 2015 Annual Report. “Programmatic risk can lead to tradeoffs that are inconsistent with good safety practice.”

Commercial crew has been significantly underfunded over the years, with Congress providing far less money than NASA said it needed. The shortfall has led to delays in the program and “resulted in a design at Critical Design Review that was not as mature as it might have been,” ASAP said.

Boeing and SpaceX are building commercial crew vehicles to take crews to and from the International Space Station. ASAP expressed concerns about schedule pressures on both companies to fly crews in 2017.

Meanwhile, the Space Launch System and Orion crew vehicle — which are designed for deep space exploration — have not lacked for funding. However, the funding levels have been essentially flat.

“Historically, most successful programs have reflected a bias towards robust, early funding to support critical design and system decisions,” ASAP said. “Both the amount of resources available and the time distribution of when the funds become available are issues for Exploration Systems Development (ESD) as well as the Commercial Crew Program (CCP).”

The end result has been an increase in risk, including a rise in the maximum acceptable Loss of Crew (LOC) probabilities for SLS and Orion.

“Over the past year, the Panel has noted a continuing and unacknowledged accretion of risk in space flight programs that we believe has the potential to significantly impact crew safety and the safe execution of human space missions,” the report states. “The Panel’s concern is not the result of singular action but the accumulated impact of decisions made and risks assumed—either explicitly or tacitly, in small or large steps—that have mounted up and led to an apparent erosion of safety.”

The International Space Station, which celebrate 15 years of continuous habitation in November, was the one real bright spot in the ASAP report.

“The openness and transparency of the ISS Program have built confidence within this Panel and with others that the program management is in command of the issues,” the report states. “The Program addresses each issue that arises, solves the problem, learns from the experience, adjusts procedures and technologies appropriately, and applies the emerging knowledge to future endeavors. The ISS Program has shown itself to be a learning organization.”

The panel was impressed with how well the station operated despite the loss of the U.S. Cygnus and Dragon cargo ships and a Russian Progress freighter between October 2014 and June 2015.

“Transportation planning and inventory is an incredible balancing act,” ASAP said. “The Program’s ability to continue ISS operations and scientific research after the loss of three ISS support missions is a tribute to the ISS planners and logisticians.”

Key excerpts from the report follow. Download the full report here.

NASA Aerospace Safety Advisory Panel (ASAP)

2015 Annual Report

Key Excerpts

Funding Adequacy and Profile



As we noted in our 2014 Annual Report and continue to assert this year, NASA’s budget is insufficient to deliver all current undertakings with acceptable programmatic risk. Programmatic risk can lead to tradeoffs that are inconsistent with good safety practice. Historically, most successful programs have reflected a bias towards robust, early funding to support critical design and system decisions. Both the amount of resources available and the time distribution of when the funds become available are issues for Exploration Systems Development (ESD) as well as the Commercial Crew Program (CCP).

The CCP was underfunded during the critical early years of development. Specifically, the Program received only 57 percent of the requested funding in fiscal year (FY) 2011 through FY 2013. This underfunding in the critical early system design years resulted in a design at Critical Design Review that was not as mature as it might have been. This has also added to the program management and safety challenges. Going forward, there is high risk that the program may not receive sufficient funding to execute the planned program. Careful attention and close cooperation among NASA, the White House, and the Congress is necessary to deliver safe and effective transportation to low-Earth orbit. Again, the ASAP strongly believes competition between two suppliers is essential to ensuring the best and safest design, given the fixed-price contracting strategy.

ESD funding is presented in similar fashion in Figure 3. ESD has been resourced at a greater level than the President’s Budget Request by an average of 10.5 percent during FY 2012 through FY 2015. However, the funding profile has been essentially flat. This distribution of resources reflects one more typically observed in “level-of-effort” programs rather than a budget constructed to achieve the needed design efforts of a major program’s discrete and integrated requirements. In addition, funding is appropriated for individual elements rather than the program as a whole, which limits NASA’s ability to more efficiently allocate resources to prudently address issues. As noted in the conclusion section of the ASAP’s 2014 Annual Report, NASA’s response has been to embrace “…a strategy of ‘capabilities-based’ investments. This strategy develops and matures many of the new technologies and methodologies required for the future but does not deliver an integrated capability.

Accretion of Risk

Over the past year, the Panel has noted a continuing and unacknowledged accretion of risk in space flight programs that we believe has the potential to significantly impact crew safety and the safe execution of human space missions. The Panel’s concern is not the result of singular action but the accumulated impact of decisions made and risks assumed—either explicitly or tacitly, in small or large steps—that have mounted up and led to an apparent erosion of safety. While the ASAP does not assume that a challenging endeavor such as space exploration can be undertaken free of risk, we have consistently stated that, in a healthy, risk-management environment, risks should be deliberately and thoroughly vetted, balanced against the expected gain from taking the risk, and acknowledged candidly and with clear accountability and documentation.

While the programs appear to recognize and accept risk growth in many individual situations, we are not convinced that NASA recognizes or clearly communicates the aggregated impact of individually accepted component risks. Despite the ASAP’s long-standing recommendation, NASA is not clearly and transparently communicating the recognition of the accreted risk, its impact to overall safety, and the rationale of why the increased risk is acceptable. This leaves the ASAP uncertain as to whether this accretion of risk is prudent or not. In some situations, NASA has characterized the changes as negligible and portrayed them as necessary and prudent actions that must be taken to maintain a schedule that appears to us to be an overly restrictive and internally imposed constraint.

Subsequent sections of this Report will provide details pertaining to our specific concerns, but the kind of situations that have led to our disquiet include:

The test program for components of Exploration Systems Development (ESD) appears to have gradually eroded since 2010. Among the multiple changes that have diminished the testing rigor are the decisions to reduce the scope of the Ascent Abort 2 (AA2) test and to delete pyrotechnic (pyro) shock/separation testing at the integrated system level.

Late changes are being made to the Orion heat shield design with only one opportunity (Exploration Mission-1) to flight test the new design prior to the first crewed mission.

Exploration Mission (EM)-2 is scheduled as the first crewed flight of the Space Launch System (SLS) and the first flight of the Orion environmental control and life support system (ECLSS). This system will not have had an end-to-end flight test to build confidence that it will function safely during a cislunar mission where return to Earth could require up to as much as 11 days. This plan appears to incur an increased risk without a clearly articulated rationale.

The SLS infrequent flight rate leads to higher risk due to mission operations team personnel loss and fading memories of lessons learned. EM-1 is scheduled to launch in mid-2018, and EM-2 is scheduled for launch between 2021 and 2023. NASA has told the ASAP that the intent is to launch once per year subsequent to EM-2, but the demand and schedule are vague.

There has been growth over time in the maximum acceptable Loss of Crew (LOC) probabilities. This was discussed in the ASAP’s 2014 Annual Report.

While much of the accretion of risk we have seen is in ESD, the Commercial Crew Program (CCP) is subject to budget and schedule pressures that could lead to similar incremental risk acceptance decisions. As an artifact of the transition from Space Act Agreements to the Commercial Crew contractual arrangements, hazard reporting is behind for the CCP. There is a lack of design maturity at Critical Design Review (CDR); therefore, design is going forward without the benefit of the completed hazard analyses.

Additionally, in the CCP, the lack of formality or “paperwork” aspects of design decisions and changes is a concern. There is danger that this will lead to an undesirable and unplanned or unrecognized increase in risk acceptance as schedule and budget pressures mount.

Summary

Nine topic areas, highlighted in this report, are summarized in the table on the following page. They have been broken out to focus attention on individual topics that we feel are worthy of note.

Of the nine topic areas, two are rated as red, indicating they are longstanding and have not yet been adequately addressed. We listed these overarching, red-rated issues separately, because we believe that their resolution would significantly contribute to reducing the risk across a wide range of programs and activities. Had we made these red issues a component of the other items, such as those related specifically to Exploration Systems Development (ESD) and the Commercial Crew Program (CCP), it would have compelled us to rate ESD and CCP red and may have led to misinterpretation by the reader that the red rating of ESD and CCP was due to technical factors in these programs rather than to the overarching issues of inadequate funding and risk management practices. In this way, we are highlighting the high priority we place on addressing the red issues so that a significant cross-cutting benefit can be realized by a number of programs which otherwise would continue to be in a situation of preventable jeopardy.



The topics highlighted in yellow are important issues or concerns that are either currently being addressed by NASA but are still unresolved, or are not currently being addressed by NASA. These issues will continue to be examined closely by the Panel.

One topic, the International Space Station (ISS), is indicated as green — a positive aspect that is being addressed by NASA, but continues to be followed. The ISS is the largest system humans have ever put into space, is complex, and has safely operated for over 15 years. It is being well managed, but the ASAP continues to monitor the ISS Program closely in light of the dangers associated with human space flight.