October 23, 1997
W
| To: | M/Associate Administrator for Space Flight |
| From: | W/Assistant Inspector General for Inspections and Assessments |
| Subject: | Observations and Recommendations Regarding Long-Duration Astronaut Debrief and Post-Mission Report Processes |
The Office of Inspector General (OIG) is conducting an inquiry
on U.S. participation in the Russian Mir Space Station Program.
As part of this inquiry, we examined the Phase I long-duration
astronaut debrief and post-mission report process. We believe
that NASA can improve this process so that astronaut debriefing
information is more effectively shared and utilized in the interests
of safety and mission success. Specifically, we are recommending
that NASA: (1) improve the scheduling and subsequent dissemination
of the transcribed version of long-duration astronauts' debriefings
and post-mission reports; and (2) standardize the recording, storage,
and control of debriefing materials.
A. BACKGROUND
On July 11, 1997, the House Committee on Science requested the
NASA OIG to assess the Agency's participation in the Russian Mir
Space Station Program. Specifically, the OIG was asked to analyze:
(1) suitability of Russia's Mir space station for habitation
by U.S. astronauts, (2) research productivity on-board the Mir,
and (3) cost effectiveness of continued NASA involvement in the
Mir Space Station Program. These issues were preliminarily addressed
in the OIG response letter to Chairman Sensenbrenner on August
29, 1997 (revised September 12, 1997).
The astronauts provide first-hand information on systems and operations
aboard Mir during post-flight debriefings. The debriefings focus
on lessons learned to help with the planning and preparation for,
and support of, future Mir and International Space Station (ISS)
long-duration missions.
During our inquiry, we obtained long-duration astronaut debriefings
in various media: audio and video tapes, summary reports, and
transcripts. Based on our interviews and observations to date,
the scheduling, recording, dissemination, storage, control and
use of astronaut debriefing information can be improved. Although
the Agency has certain debriefing and post-mission report procedures
and processes in place, they are inconsistently implemented and/or
inadequately followed to the detriment of the ISS Program. [Note
1]
B. NEED FOR TIMELY SCHEDULING AND WIDER DISSEMINATION OF
ASTRONAUT DEBRIEFINGS AND POST-MISSION REPORTS
1. Process
The existing Debrief/Post-Mission Report Process consists of several
steps involving different officials and teams. [Note2] Detailed
debriefing schedules are developed for each returning astronaut.
[Note 3] In general, the returning crew member is provided a
list of questions in advance of the debriefing sessions. The
debriefings are informal and may be recorded with the permission
of the crew member. Notes are taken by the teams and moderator,
who then provide a draft report which the crew member reviews
and approves. Copies of debriefings are forwarded to the Phase
1 Program Office. In addition, the Phase 1 Program Manager and
the Director of Flight Crew Operations also conduct one-on-one
debriefing sessions. However, neither of these two officials
reduces their debriefings to a formal written or taped report
for the record. The debriefing process includes a final post-mission
report completed by the long-duration astronaut. During the drafting
of this report, only one astronaut had completed a final post-mission
report. Two long-duration astronauts had separated from NASA
without completing a final report. Obviously, such a report could
offer valuable insights for safety and mission success if it is
timely and is disseminated to the groups with operational and
oversight responsibilities. [Note 4]
2. Dissemination
Existing guidelines call for a subject matter team leader to distribute
the debriefing report to the remainder of the team and the Phase
I Project Office. The guidelines specify that lessons learned
and actions identified in the final post-mission report be reviewed
by the Astronaut Office and the Phase 1 Program Office. This
information is then entered into the "Postflight Crew Recommendation"
database for tracking actions and referrals. The guidelines also
stipulate that appropriate actions will be assigned to NASA organizations
to address these issues (See Appendix A). However, there is no
requirement that the lessons learned be reviewed by Headquarters
offices such as the Office of Safety and Mission Assurance or
the Office of Space Flight.
As of the date of this correspondence, only one astronaut's final
debriefing report is in the database. The database, started for
the STS-69 Shuttle mission, is updated quarterly and routinely
distributed to organizations and officials within Johnson Space
Center (e.g., Center Director, Mission Operations Directorate,
Phase I Program Office, ISS, etc.). Contents of the database
come from the Shuttle post-flight and post-mission reports of
the astronauts.
The debriefings and final post-mission reports are not routinely
disseminated to the NASA advisory committees (e.g., NASA Advisory
Council and its advisory committees and the NASA Aerospace Safety
Advisory Panel). As specific issues arise, some advisory committees
have contacted astronauts directly or requested debriefing materials.
The Shuttle/Mir Rendezvous/Docking Missions and ISS Operational
Readiness Task Force (known as the Stafford Task Force) is not
routinely included on all long-duration astronaut debriefing distribution
lists. The debriefings contain information which could be useful
to them in their evaluations and recommendations. [Note 5] For
example, during a debriefing in October 1996, 5 months before
the fire on-board Mir in February 1997, an astronaut discussed
fire emergency equipment and drills. The astronaut reported knowing
where the emergency equipment (masks and extinguishers) was located,
and recalled only one drill during the first month in orbit. [Note
6] Upon reviewing this debriefing, an outside group applying appropriately
rigorous safety standards may have questioned the adequacy of
fire procedures and drills, raised questions about the availability
and suitability of the fire-fighting equipment, recommended the
need for more fire drills, and specifically asked for details
related to the potential fire hazards. These issues are better
raised before, not after a life-threatening event. [Note
7]
Debriefing materials are not centrally located, but are maintained
by the various subject matter teams (e.g., Crew Systems, Operations,
Payloads, ISS, etc.). Thus, there is no single collection point
for the documents, which makes the distribution process far less
efficient.
Recommendations. We recommend that the Office of
Space Flight (OSF) monitor the long-duration astronaut post-flight
debriefing process to ensure that: (1) all sessions are scheduled
and conducted in a timely manner, (2) astronaut debriefings are
routinely distributed to key personnel and oversight managers
at NASA Headquarters, and (3) the NASA Advisory Council and other
appropriate advisory committees are routinely provided debriefing
reports. (In the case of transcribed records, summaries, and
post-flight recommendations and actions, OSF can facilitate distribution
through electronic mail.) More specifically, we recommend that:
C. RECORDING, STORAGE & CONTROL OF DEBRIEFING MATERIALS
NASA uses several different approaches to memorialize debriefings.
Some debriefing teams audio or video tape sessions without preparing
transcripts. Other teams summarize debriefing sessions based
on notes. Standardizing the debriefing formats by requiring both
transcripts of audio or video tapes and written summaries will
facilitate simultaneous analysis by diverse groups. In this way,
immediate safety and mission issues will be disseminated in a
comprehensive manner and future actions can be assigned.
We recognize that astronauts may discuss highly sensitive information
for which dissemination should be more restricted. For example,
astronauts may discuss their medical conditions. They may also
want to discuss opinions about crew or ground performance (e.g.,
negligence or misconduct). These communications, too, generally
should be reduced to a written report because of their importance
to evaluators (e.g., doctors, safety specialists, etc.). NASA
may wish to restrict the dissemination of these reports. Restrictions
should be clearly marked on the report (e.g., Privacy Act warnings)
and these documents maintained separately in accordance with prudent
physical security procedures. At present, NASA has no comprehensive
policy and procedures regarding the dissemination of sensitive
debriefing materials. [Note 9]
Recommendations. We recommend that the Office of
Space Flight review the long-duration astronaut debriefing process
to ensure that effective recording and transcribing procedures
are applied for all sessions with special precautions taken for
highly sensitive information. Specifically, we recommend that:
D. SUMMARY & EVALUATION OF NASA MANAGEMENT'S RESPONSE
We received NASA's response to our draft report on October 21,
1997 (See Appendix C). The response stated that the "report
is accurate and makes sound recommendations." However, the
Agency took exception to:
We have indications that the Agency has moved to improve its debriefing
and post-mission reporting processes. We will continue to review
the process and evaluate the application of the recommended changes.
Conclusion
The lessons learned from the experiences, observations, and impressions
of our long-duration astronauts are vital in ensuring safety and
productivity in the development of the ISS. A principal way to
surface these lessons learned is through wide and timely distribution
of debriefing materials. This information should be reviewed
by all involved in the development and operation of the ISS, including
those at Headquarters providing oversight. NASA has traditionally
turned to non-government sources for independent judgment and
guidance, including its own NASA Advisory Council. In keeping
with this oversight mechanism, the appropriate advisory committees
also should routinely review the astronaut debriefing materials.
We believe the recommendations we have made will enhance ISS
safety and mission success.
/original signed by/
David M. Cushing
Enclosures
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IG Chron
[Note 1] In September 1977, the Inspector General
(IG) communicated to the NASA Administrator general concerns about
astronaut communications, including the debriefing process. The
Administrator indicated he will promptly followup in the area
of astronaut communications. The IG also indicated to the Young
Task Force (Mr. A. Thomas Young, Mr. Laurence J. Adams, Major
General Charles F. Bolden, Jr., Ms. Barbara Corn) that the OIG would be doing followup
regarding the debriefing process. (The Young Task Force was assembled
at the request of the NASA Administrator to review the OIG response
letter to the Honorable F. James Sensenbrenner, Chair, House Committee
on Science).
[Note 2] See Appendix A, Crew Exchange and Training
Working Group, Debrief and Post-Mission Report Process, May 2,
1997.
[Note 3] See Appendix B, Breakout of Generic LDM
Crew Post Flight Schedule and STS-84 Crew Activity Schedule.
[Note 4] The usefulness of a final report by a long-duration
astronaut is apparent from looking at the one prepared by Shannon
Lucid. She included some key recommendations which generally
have been adopted in areas such as organizing daily on-flight
activities, family support during flight, post-flight activities,
etc. She also made a key observation which deserves more study:
crew capability (". . . I think this is the most important
aspect of a long-duration flight. . .").
[Note 5] The Young Task Force specifically stated
in their recommendations that ". . . the safety and mission
success inputs of the U.S. astronauts who have flown as Mir crew
members need to be included as a part of the review process for
critical Shuttle/Mir functions and as critical inputs to the development
process for the International Space Station. We believe the Mir
related part of this recommendation needs to be implemented prior
to the transfer of the next American astronaut to Mir on STS-86."
[Note 6]. Astronaut's Debrief dated October 15, 1996:
Q: Do you feel the emergency equipment; fire extinguishers, breathing masks, small portable lights, etc., were supplied for you in sufficient numbers?
A: The emergency equipment was there and I knew
where it was. I always carried my flashlight with me because
if we lost power, I would obviously want a flashlight.
Q: Do you have any suggestions for additional equipment along the categories of emergency equipment or contingency equipment that you thought was lacking or that you would like to see added?
A: We had masks. If there was a fire, we had fire
extinguishers, but I'm used to seeing fire extinguishers in red
rather than the Russian gray or blue fire extinguishers. They
do not stand out visually. Red would be a better color. Visually
speaking, if it stands out more, then it is easier to pick out
in an emergency.
Q: Did you have training drills, evacuation drills, or safety training while you were on Mir?
A: Once, during the first month. The ground set aside a block of time where we discussed getting in the Soyuz, and what we would do if there was a fire or if we became unpressurized. We spent a few hours discussing that and looking into what we would do.
[Note 7] During February 1997, astronaut Linenger reported he had been unable to get oxygen from the first gas mask he attempted to use; clamps designed to keep the fire extinguishers in place had not been removed so that the crew had to get tools to remove the clamps before they could attempt to extinguish the fire.
As a result of the fire, and other incidents, a joint
U.S./Russian safety assurance working group met (August 25- September
5, 1997). They recommended, among other matters, that the crew
follow safety measures, including wearing gloves when igniting
the canisters, having fire extinguishers and gas masks immediately
available, and monitoring cassette initiation. On September 24,
1997, the Stafford Task Force Red Team recommended: "If
not currently practiced, regular reviews of fire procedures (i.e.,
fire drills) should be instituted."
[Note 8] During the drafting of this report, a second
long-duration astronaut submitted a "final report" weeks
after separating from NASA and almost 8 months after returning
from Mir. More timely submissions will be more valuable to mission
safety and assurance.
[Note 9] NASA obviously applies the Privacy Act
and FOIA to data, as applicable (e.g., medical information).
Nevertheless, there is no general policy regarding the dissemination
of long-duration astronaut debriefing post-flight materials.
National Aeronautics and Space Administration (NASA) Officials-In-Charge
A/Administrator
AD/Acting Deputy Administrator
AT/Associate Deputy Administrator (Technical)
G/General Counsel
J/Associate Administrator for Management Systems and Facilities
L/Associate Administrator for Legislative Affairs
M/Associate Administrator for Space Flight
P/Associate Administrator for Public Affairs
Q/Associate Administrator for Safety and Mission Assurance
U/Associate Administrator for Life & Microgravity Sciences & Applications
Z/Associate Administrator for Policy and Plans
Director, Johnson Space Center
NASA Advisory Council Officials
Chairman, NASA Advisory Committee
Chairman, NASA Aerospace Advisory Council
Chairman, Advisory Committee on the International Space Station
Chairman, Shuttle/Mir Rendezvous/Docking Missions and ISS Operational
Readiness Task Forces
Chairman and Ranking Minority Member of each of the following
Congressional Committees and Subcommittees:
Senate Committee on Appropriations
Senate Subcommittee on VA-HUD-Independent Agencies
Senate Committee on Commerce, Science and Transportation
Senate Subcommittee on Science, Technology and Space
Senate Committee on Governmental Affairs
House Committee on Appropriations
House Subcommittee on VA-HUD-Independent Agencies
House Committee on Government Reform and Oversight
House Subcommittee on National Security, International Affairs, and Criminal Justice
House Committee on Science
House Subcommittee on Space and Aeronautics
For copies of the graphic appendices, contact Dana M. Mellerio, (202) 358-0271