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

OF THE

NASA AGENCY-WIDE APPLICABILITY

OF THE

COLUMBIA ACCIDENT INVESTIGATION BOARD

REPORT

A RENEWED COMMITMENT TO EXCELLENCE

i ii i

1

February 1, 2003 was a turning point in the history of NASA. February 1, 2003 was a turning point in the history of NASA. February 1, 2003 was a turning point in the history of NASA. February 1, 2003 was a turning point in the history of NASA. February 1, 2003 was a turning point in the history of NASA. February 1, 2003 was a turning point in the history of NASA. February 1, 2003 was a turning point in the history of NASA. February 1, 2003 was a turning point in the history of NASA. February 1, 2003 was a turning point in the history of NASA. February 1, 2003 was a turning point in the history of NASA. February 1, 2003 was a turning point in the history of NASA. February 1, 2003 was a turning point in the history of NASA. February 1, 2003 was a turning point in the history of NASA. There had been accidents before the loss of Shuttle There had been accidents before the loss of Shuttle There had been accidents before the loss of Shuttle There had been accidents before the loss of Shuttle There had been accidents before the loss of Shuttle There had been accidents before the loss of Shuttle There had been accidents before the loss of Shuttle There had been accidents before the loss of Shuttle There had been accidents before the loss of Shuttle There had been accidents before the loss of Shuttle ColumbiaColumbiaColumbiaand its crew, and there had been Agency reviews, both internal and its crew, and there had been Agency reviews, both internal and its crew, and there had been Agency reviews, both internal and its crew, and there had been Agency reviews, both internal and its crew, and there had been Agency reviews, both internal and its crew, and there had been Agency reviews, both internal and its crew, and there had been Agency reviews, both internal and its crew, and there had been Agency reviews, both internal and its crew, and there had been Agency reviews, both internal and its crew, and there had been Agency reviews, both internal and its crew, and there had been Agency reviews, both internal and its crew, and there had been Agency reviews, both internal and its crew, and there had been Agency reviews, both internal and external. Although these prior accidents and subsequent in-and external. Although these prior accidents and subsequent in-and external. Although these prior accidents and subsequent in-and external. Although these prior accidents and subsequent in-and external. Although these prior accidents and subsequent in-and external. Although these prior accidents and subsequent in-and external. Although these prior accidents and subsequent in-and external. Although these prior accidents and subsequent in-and external. Although these prior accidents and subsequent in-and external. Although these prior accidents and subsequent in-and external. Although these prior accidents and subsequent in-and external. Although these prior accidents and subsequent in-vestigations provided NASA opportunities to learn and evolve, vestigations provided NASA opportunities to learn and evolve, vestigations provided NASA opportunities to learn and evolve, vestigations provided NASA opportunities to learn and evolve, vestigations provided NASA opportunities to learn and evolve, vestigations provided NASA opportunities to learn and evolve, vestigations provided NASA opportunities to learn and evolve, vestigations provided NASA opportunities to learn and evolve, vestigations provided NASA opportunities to learn and evolve, vestigations provided NASA opportunities to learn and evolve, vestigations provided NASA opportunities to learn and evolve, vestigations provided NASA opportunities to learn and evolve, vestigations provided NASA opportunities to learn and evolve, the the Columbia Columbia accident made it painfully clear that NASA̓ s safety accident made it painfully clear that NASA̓ s safety accident made it painfully clear that NASA̓ s safety accident made it painfully clear that NASA̓ s safety accident made it painfully clear that NASA̓ s safety accident made it painfully clear that NASA̓ s safety accident made it painfully clear that NASA̓ s safety accident made it painfully clear that NASA̓ s safety accident made it painfully clear that NASA̓ s safety accident made it painfully clear that NASA̓ s safety and reliability performance was still falling short. What was lost and reliability performance was still falling short. What was lost and reliability performance was still falling short. What was lost and reliability performance was still falling short. What was lost and reliability performance was still falling short. What was lost and reliability performance was still falling short. What was lost and reliability performance was still falling short. What was lost and reliability performance was still falling short. What was lost and reliability performance was still falling short. What was lost and reliability performance was still falling short. What was lost and reliability performance was still falling short. What was lost and reliability performance was still falling short. What was lost that day were not only seven lives and an historic spacecraft, but that day were not only seven lives and an historic spacecraft, but that day were not only seven lives and an historic spacecraft, but that day were not only seven lives and an historic spacecraft, but that day were not only seven lives and an historic spacecraft, but that day were not only seven lives and an historic spacecraft, but that day were not only seven lives and an historic spacecraft, but that day were not only seven lives and an historic spacecraft, but that day were not only seven lives and an historic spacecraft, but that day were not only seven lives and an historic spacecraft, but that day were not only seven lives and an historic spacecraft, but that day were not only seven lives and an historic spacecraft, but that day were not only seven lives and an historic spacecraft, but also the confi dence that NASA knew how to identify problems also the confi dence that NASA knew how to identify problems also the confi dence that NASA knew how to identify problems also the confi dence that NASA knew how to identify problems also the confi dence that NASA knew how to identify problems also the confi dence that NASA knew how to identify problems also the confi dence that NASA knew how to identify problems also the confi dence that NASA knew how to identify problems also the confi dence that NASA knew how to identify problems also the confi dence that NASA knew how to identify problems also the confi dence that NASA knew how to identify problems also the confi dence that NASA knew how to identify problems and resolve them properly.and resolve them properly.and resolve them properly.and resolve them properly.and resolve them properly.and resolve them properly.

The Columbia Accident Investigation Board (CAIB) was estab-The Columbia Accident Investigation Board (CAIB) was estab-The Columbia Accident Investigation Board (CAIB) was estab-The Columbia Accident Investigation Board (CAIB) was estab-The Columbia Accident Investigation Board (CAIB) was estab-The Columbia Accident Investigation Board (CAIB) was estab-The Columbia Accident Investigation Board (CAIB) was estab-The Columbia Accident Investigation Board (CAIB) was estab-The Columbia Accident Investigation Board (CAIB) was estab-The Columbia Accident Investigation Board (CAIB) was estab-The Columbia Accident Investigation Board (CAIB) was estab-The Columbia Accident Investigation Board (CAIB) was estab-The Columbia Accident Investigation Board (CAIB) was estab-lished within hours of the Shuttleʼs loss, and the Board proceeded lished within hours of the Shuttleʼs loss, and the Board proceeded lished within hours of the Shuttleʼs loss, and the Board proceeded lished within hours of the Shuttleʼs loss, and the Board proceeded lished within hours of the Shuttleʼs loss, and the Board proceeded lished within hours of the Shuttleʼs loss, and the Board proceeded lished within hours of the Shuttleʼs loss, and the Board proceeded lished within hours of the Shuttleʼs loss, and the Board proceeded lished within hours of the Shuttleʼs loss, and the Board proceeded lished within hours of the Shuttleʼs loss, and the Board proceeded lished within hours of the Shuttleʼs loss, and the Board proceeded lished within hours of the Shuttleʼs loss, and the Board proceeded to work independently and thoroughly to fi gure out what went to work independently and thoroughly to fi gure out what went to work independently and thoroughly to fi gure out what went to work independently and thoroughly to fi gure out what went to work independently and thoroughly to fi gure out what went to work independently and thoroughly to fi gure out what went to work independently and thoroughly to fi gure out what went to work independently and thoroughly to fi gure out what went to work independently and thoroughly to fi gure out what went to work independently and thoroughly to fi gure out what went to work independently and thoroughly to fi gure out what went to work independently and thoroughly to fi gure out what went to work independently and thoroughly to fi gure out what went wrong. Accident investigators traditionally include a determina-wrong. Accident investigators traditionally include a determina-wrong. Accident investigators traditionally include a determina-wrong. Accident investigators traditionally include a determina-wrong. Accident investigators traditionally include a determina-wrong. Accident investigators traditionally include a determina-wrong. Accident investigators traditionally include a determina-wrong. Accident investigators traditionally include a determina-wrong. Accident investigators traditionally include a determina-wrong. Accident investigators traditionally include a determina-wrong. Accident investigators traditionally include a determina-wrong. Accident investigators traditionally include a determina-tion of “probable cause” in their reports, but the CAIB Report has tion of “probable cause” in their reports, but the CAIB Report has tion of “probable cause” in their reports, but the CAIB Report has tion of “probable cause” in their reports, but the CAIB Report has tion of “probable cause” in their reports, but the CAIB Report has tion of “probable cause” in their reports, but the CAIB Report has tion of “probable cause” in their reports, but the CAIB Report has tion of “probable cause” in their reports, but the CAIB Report has tion of “probable cause” in their reports, but the CAIB Report has tion of “probable cause” in their reports, but the CAIB Report has tion of “probable cause” in their reports, but the CAIB Report has tion of “probable cause” in their reports, but the CAIB Report has two causal statements, one “physical,” the other “organizational.” two causal statements, one “physical,” the other “organizational.” two causal statements, one “physical,” the other “organizational.” two causal statements, one “physical,” the other “organizational.” two causal statements, one “physical,” the other “organizational.” two causal statements, one “physical,” the other “organizational.” two causal statements, one “physical,” the other “organizational.” two causal statements, one “physical,” the other “organizational.” two causal statements, one “physical,” the other “organizational.” two causal statements, one “physical,” the other “organizational.” two causal statements, one “physical,” the other “organizational.” two causal statements, one “physical,” the other “organizational.” two causal statements, one “physical,” the other “organizational.” The physical causes are the sequence of events on Shuttle Mission The physical causes are the sequence of events on Shuttle Mission The physical causes are the sequence of events on Shuttle Mission The physical causes are the sequence of events on Shuttle Mission The physical causes are the sequence of events on Shuttle Mission The physical causes are the sequence of events on Shuttle Mission The physical causes are the sequence of events on Shuttle Mission The physical causes are the sequence of events on Shuttle Mission The physical causes are the sequence of events on Shuttle Mission The physical causes are the sequence of events on Shuttle Mission The physical causes are the sequence of events on Shuttle Mission The physical causes are the sequence of events on Shuttle Mission STS-107 that destroyed the Orbiter; the organizational causes are STS-107 that destroyed the Orbiter; the organizational causes are STS-107 that destroyed the Orbiter; the organizational causes are STS-107 that destroyed the Orbiter; the organizational causes are STS-107 that destroyed the Orbiter; the organizational causes are STS-107 that destroyed the Orbiter; the organizational causes are STS-107 that destroyed the Orbiter; the organizational causes are STS-107 that destroyed the Orbiter; the organizational causes are STS-107 that destroyed the Orbiter; the organizational causes are STS-107 that destroyed the Orbiter; the organizational causes are STS-107 that destroyed the Orbiter; the organizational causes are STS-107 that destroyed the Orbiter; the organizational causes are STS-107 that destroyed the Orbiter; the organizational causes are the failures within NASA that allowed those events to occur. the failures within NASA that allowed those events to occur. the failures within NASA that allowed those events to occur. the failures within NASA that allowed those events to occur. the failures within NASA that allowed those events to occur. the failures within NASA that allowed those events to occur. the failures within NASA that allowed those events to occur. the failures within NASA that allowed those events to occur. the failures within NASA that allowed those events to occur. the failures within NASA that allowed those events to occur. the failures within NASA that allowed those events to occur.

The CAIB released its Report in August 2003, followed by fi ve The CAIB released its Report in August 2003, followed by fi ve The CAIB released its Report in August 2003, followed by fi ve The CAIB released its Report in August 2003, followed by fi ve The CAIB released its Report in August 2003, followed by fi ve The CAIB released its Report in August 2003, followed by fi ve The CAIB released its Report in August 2003, followed by fi ve The CAIB released its Report in August 2003, followed by fi ve The CAIB released its Report in August 2003, followed by fi ve The CAIB released its Report in August 2003, followed by fi ve The CAIB released its Report in August 2003, followed by fi ve The CAIB released its Report in August 2003, followed by fi ve volumes of appendix material in October, and with that the volumes of appendix material in October, and with that the volumes of appendix material in October, and with that the volumes of appendix material in October, and with that the volumes of appendix material in October, and with that the volumes of appendix material in October, and with that the volumes of appendix material in October, and with that the volumes of appendix material in October, and with that the volumes of appendix material in October, and with that the volumes of appendix material in October, and with that the volumes of appendix material in October, and with that the volumes of appendix material in October, and with that the Boardʼs work was concluded. But the job for NASA was just Boardʼs work was concluded. But the job for NASA was just Boardʼs work was concluded. But the job for NASA was just Boardʼs work was concluded. But the job for NASA was just Boardʼs work was concluded. But the job for NASA was just Boardʼs work was concluded. But the job for NASA was just Boardʼs work was concluded. But the job for NASA was just Boardʼs work was concluded. But the job for NASA was just Boardʼs work was concluded. But the job for NASA was just Boardʼs work was concluded. But the job for NASA was just Boardʼs work was concluded. But the job for NASA was just Boardʼs work was concluded. But the job for NASA was just beginning. In the months following the loss of beginning. In the months following the loss of beginning. In the months following the loss of beginning. In the months following the loss of beginning. In the months following the loss of beginning. In the months following the loss of beginning. In the months following the loss of beginning. In the months following the loss of beginning. In the months following the loss of Columbia Columbia and her and her and her crew, the Agency had been making both technical and procedural crew, the Agency had been making both technical and procedural crew, the Agency had been making both technical and procedural crew, the Agency had been making both technical and procedural crew, the Agency had been making both technical and procedural crew, the Agency had been making both technical and procedural crew, the Agency had been making both technical and procedural crew, the Agency had been making both technical and procedural crew, the Agency had been making both technical and procedural crew, the Agency had been making both technical and procedural crew, the Agency had been making both technical and procedural crew, the Agency had been making both technical and procedural crew, the Agency had been making both technical and procedural changes, based on its own examination of the accident and on changes, based on its own examination of the accident and on changes, based on its own examination of the accident and on changes, based on its own examination of the accident and on changes, based on its own examination of the accident and on changes, based on its own examination of the accident and on changes, based on its own examination of the accident and on changes, based on its own examination of the accident and on changes, based on its own examination of the accident and on changes, based on its own examination of the accident and on changes, based on its own examination of the accident and on changes, based on its own examination of the accident and on interim recommendations from the CAIB. Once the investigation interim recommendations from the CAIB. Once the investigation interim recommendations from the CAIB. Once the investigation interim recommendations from the CAIB. Once the investigation interim recommendations from the CAIB. Once the investigation interim recommendations from the CAIB. Once the investigation interim recommendations from the CAIB. Once the investigation interim recommendations from the CAIB. Once the investigation interim recommendations from the CAIB. Once the investigation interim recommendations from the CAIB. Once the investigation interim recommendations from the CAIB. Once the investigation interim recommendations from the CAIB. Once the investigation interim recommendations from the CAIB. Once the investigation Report was made public, those efforts accelerated.Report was made public, those efforts accelerated.Report was made public, those efforts accelerated.Report was made public, those efforts accelerated.Report was made public, those efforts accelerated.Report was made public, those efforts accelerated.Report was made public, those efforts accelerated.Report was made public, those efforts accelerated.Report was made public, those efforts accelerated.

The NASA Administrator Sean OʼKeefe chartered an executive The NASA Administrator Sean OʼKeefe chartered an executive The NASA Administrator Sean OʼKeefe chartered an executive The NASA Administrator Sean OʼKeefe chartered an executive The NASA Administrator Sean OʼKeefe chartered an executive The NASA Administrator Sean OʼKeefe chartered an executive The NASA Administrator Sean OʼKeefe chartered an executive The NASA Administrator Sean OʼKeefe chartered an executive The NASA Administrator Sean OʼKeefe chartered an executive The NASA Administrator Sean OʼKeefe chartered an executive The NASA Administrator Sean OʼKeefe chartered an executive The NASA Administrator Sean OʼKeefe chartered an executive team, which came to be known as the Diaz Team, and gave it team, which came to be known as the Diaz Team, and gave it team, which came to be known as the Diaz Team, and gave it team, which came to be known as the Diaz Team, and gave it team, which came to be known as the Diaz Team, and gave it team, which came to be known as the Diaz Team, and gave it team, which came to be known as the Diaz Team, and gave it team, which came to be known as the Diaz Team, and gave it team, which came to be known as the Diaz Team, and gave it team, which came to be known as the Diaz Team, and gave it team, which came to be known as the Diaz Team, and gave it team, which came to be known as the Diaz Team, and gave it the assignment of identifying those CAIB Report elements with the assignment of identifying those CAIB Report elements with the assignment of identifying those CAIB Report elements with the assignment of identifying those CAIB Report elements with the assignment of identifying those CAIB Report elements with the assignment of identifying those CAIB Report elements with the assignment of identifying those CAIB Report elements with the assignment of identifying those CAIB Report elements with the assignment of identifying those CAIB Report elements with the assignment of identifying those CAIB Report elements with the assignment of identifying those CAIB Report elements with the assignment of identifying those CAIB Report elements with the assignment of identifying those CAIB Report elements with Agency-wide applicability and developing measures to address Agency-wide applicability and developing measures to address Agency-wide applicability and developing measures to address Agency-wide applicability and developing measures to address Agency-wide applicability and developing measures to address Agency-wide applicability and developing measures to address Agency-wide applicability and developing measures to address Agency-wide applicability and developing measures to address Agency-wide applicability and developing measures to address Agency-wide applicability and developing measures to address Agency-wide applicability and developing measures to address Agency-wide applicability and developing measures to address each one. What follows is the Report of that team. It should be each one. What follows is the Report of that team. It should be each one. What follows is the Report of that team. It should be each one. What follows is the Report of that team. It should be each one. What follows is the Report of that team. It should be each one. What follows is the Report of that team. It should be each one. What follows is the Report of that team. It should be each one. What follows is the Report of that team. It should be each one. What follows is the Report of that team. It should be each one. What follows is the Report of that team. It should be each one. What follows is the Report of that team. It should be each one. What follows is the Report of that team. It should be each one. What follows is the Report of that team. It should be noted that while the Team focused on the organizational causes noted that while the Team focused on the organizational causes noted that while the Team focused on the organizational causes noted that while the Team focused on the organizational causes noted that while the Team focused on the organizational causes noted that while the Team focused on the organizational causes noted that while the Team focused on the organizational causes noted that while the Team focused on the organizational causes noted that while the Team focused on the organizational causes noted that while the Team focused on the organizational causes noted that while the Team focused on the organizational causes noted that while the Team focused on the organizational causes described in the CAIB Report which were related to NASA̓ s described in the CAIB Report which were related to NASA̓ s described in the CAIB Report which were related to NASA̓ s described in the CAIB Report which were related to NASA̓ s described in the CAIB Report which were related to NASA̓ s described in the CAIB Report which were related to NASA̓ s described in the CAIB Report which were related to NASA̓ s described in the CAIB Report which were related to NASA̓ s described in the CAIB Report which were related to NASA̓ s described in the CAIB Report which were related to NASA̓ s described in the CAIB Report which were related to NASA̓ s described in the CAIB Report which were related to NASA̓ s described in the CAIB Report which were related to NASA̓ s culture, the Team did not do a broad, in-depth assessment of the culture, the Team did not do a broad, in-depth assessment of the culture, the Team did not do a broad, in-depth assessment of the culture, the Team did not do a broad, in-depth assessment of the culture, the Team did not do a broad, in-depth assessment of the culture, the Team did not do a broad, in-depth assessment of the culture, the Team did not do a broad, in-depth assessment of the culture, the Team did not do a broad, in-depth assessment of the culture, the Team did not do a broad, in-depth assessment of the culture, the Team did not do a broad, in-depth assessment of the culture, the Team did not do a broad, in-depth assessment of the culture, the Team did not do a broad, in-depth assessment of the cultural changes needed to address the organizational causes. cultural changes needed to address the organizational causes. cultural changes needed to address the organizational causes. cultural changes needed to address the organizational causes. cultural changes needed to address the organizational causes. cultural changes needed to address the organizational causes. cultural changes needed to address the organizational causes. cultural changes needed to address the organizational causes. cultural changes needed to address the organizational causes. cultural changes needed to address the organizational causes. cultural changes needed to address the organizational causes. cultural changes needed to address the organizational causes. cultural changes needed to address the organizational causes. The Team focused specifi cally on the CAIB Report and those The Team focused specifi cally on the CAIB Report and those The Team focused specifi cally on the CAIB Report and those The Team focused specifi cally on the CAIB Report and those The Team focused specifi cally on the CAIB Report and those The Team focused specifi cally on the CAIB Report and those The Team focused specifi cally on the CAIB Report and those The Team focused specifi cally on the CAIB Report and those The Team focused specifi cally on the CAIB Report and those The Team focused specifi cally on the CAIB Report and those The Team focused specifi cally on the CAIB Report and those The Team focused specifi cally on the CAIB Report and those Recommendations, Observations, and Findings (R-O-Fs) that Recommendations, Observations, and Findings (R-O-Fs) that Recommendations, Observations, and Findings (R-O-Fs) that Recommendations, Observations, and Findings (R-O-Fs) that Recommendations, Observations, and Findings (R-O-Fs) that Recommendations, Observations, and Findings (R-O-Fs) that Recommendations, Observations, and Findings (R-O-Fs) that Recommendations, Observations, and Findings (R-O-Fs) that Recommendations, Observations, and Findings (R-O-Fs) that Recommendations, Observations, and Findings (R-O-Fs) that Recommendations, Observations, and Findings (R-O-Fs) that Recommendations, Observations, and Findings (R-O-Fs) that had broad Agency-wide application beyond the Human Space had broad Agency-wide application beyond the Human Space had broad Agency-wide application beyond the Human Space had broad Agency-wide application beyond the Human Space had broad Agency-wide application beyond the Human Space had broad Agency-wide application beyond the Human Space had broad Agency-wide application beyond the Human Space had broad Agency-wide application beyond the Human Space had broad Agency-wide application beyond the Human Space had broad Agency-wide application beyond the Human Space had broad Agency-wide application beyond the Human Space had broad Agency-wide application beyond the Human Space had broad Agency-wide application beyond the Human Space Flight Program. Admittedly, some of the actions recommended Flight Program. Admittedly, some of the actions recommended Flight Program. Admittedly, some of the actions recommended Flight Program. Admittedly, some of the actions recommended Flight Program. Admittedly, some of the actions recommended Flight Program. Admittedly, some of the actions recommended Flight Program. Admittedly, some of the actions recommended Flight Program. Admittedly, some of the actions recommended Flight Program. Admittedly, some of the actions recommended Flight Program. Admittedly, some of the actions recommended Flight Program. Admittedly, some of the actions recommended Flight Program. Admittedly, some of the actions recommended

by the Team are actions one would ex-by the Team are actions one would ex-by the Team are actions one would ex-by the Team are actions one would ex-by the Team are actions one would ex-by the Team are actions one would ex-by the Team are actions one would ex-by the Team are actions one would ex-by the Team are actions one would ex-pect to see an organization take if it were pect to see an organization take if it were pect to see an organization take if it were pect to see an organization take if it were pect to see an organization take if it were pect to see an organization take if it were pect to see an organization take if it were pect to see an organization take if it were trying to change its culture, but the goals trying to change its culture, but the goals trying to change its culture, but the goals trying to change its culture, but the goals trying to change its culture, but the goals trying to change its culture, but the goals trying to change its culture, but the goals trying to change its culture, but the goals trying to change its culture, but the goals offered by the Team are intended as only offered by the Team are intended as only offered by the Team are intended as only offered by the Team are intended as only offered by the Team are intended as only offered by the Team are intended as only offered by the Team are intended as only offered by the Team are intended as only a fi rst step in the process. a fi rst step in the process. a fi rst step in the process. a fi rst step in the process. a fi rst step in the process. a fi rst step in the process. a fi rst step in the process.

Had the fate of STS-107 been the result of Had the fate of STS-107 been the result of Had the fate of STS-107 been the result of Had the fate of STS-107 been the result of Had the fate of STS-107 been the result of Had the fate of STS-107 been the result of Had the fate of STS-107 been the result of Had the fate of STS-107 been the result of a small number of well-defi ned problems a small number of well-defi ned problems a small number of well-defi ned problems a small number of well-defi ned problems a small number of well-defi ned problems a small number of well-defi ned problems a small number of well-defi ned problems a small number of well-defi ned problems a small number of well-defi ned problems in a single program, fi nding solutions in a single program, fi nding solutions in a single program, fi nding solutions in a single program, fi nding solutions in a single program, fi nding solutions in a single program, fi nding solutions in a single program, fi nding solutions in a single program, fi nding solutions would be a relatively straightforward would be a relatively straightforward would be a relatively straightforward would be a relatively straightforward would be a relatively straightforward would be a relatively straightforward would be a relatively straightforward would be a relatively straightforward would be a relatively straightforward matter. But the CAIB determined that matter. But the CAIB determined that matter. But the CAIB determined that matter. But the CAIB determined that matter. But the CAIB determined that matter. But the CAIB determined that matter. But the CAIB determined that matter. But the CAIB determined that such is not the case. It was their conclu-such is not the case. It was their conclu-such is not the case. It was their conclu-such is not the case. It was their conclu-such is not the case. It was their conclu-such is not the case. It was their conclu-such is not the case. It was their conclu-such is not the case. It was their conclu-such is not the case. It was their conclu-sion that the mistakes made on STS-107 sion that the mistakes made on STS-107 sion that the mistakes made on STS-107 sion that the mistakes made on STS-107 sion that the mistakes made on STS-107 sion that the mistakes made on STS-107 sion that the mistakes made on STS-107 sion that the mistakes made on STS-107 were not isolated failures, but rather were were not isolated failures, but rather were were not isolated failures, but rather were were not isolated failures, but rather were were not isolated failures, but rather were were not isolated failures, but rather were were not isolated failures, but rather were were not isolated failures, but rather were were not isolated failures, but rather were indicative of systemic fl aws that existed indicative of systemic fl aws that existed indicative of systemic fl aws that existed indicative of systemic fl aws that existed indicative of systemic fl aws that existed indicative of systemic fl aws that existed indicative of systemic fl aws that existed indicative of systemic fl aws that existed prior to the accident. The Diaz Team be-prior to the accident. The Diaz Team be-prior to the accident. The Diaz Team be-prior to the accident. The Diaz Team be-prior to the accident. The Diaz Team be-prior to the accident. The Diaz Team be-prior to the accident. The Diaz Team be-prior to the accident. The Diaz Team be-lieves that some of these systemic fl aws exist beyond the Shuttle lieves that some of these systemic fl aws exist beyond the Shuttle lieves that some of these systemic fl aws exist beyond the Shuttle lieves that some of these systemic fl aws exist beyond the Shuttle lieves that some of these systemic fl aws exist beyond the Shuttle lieves that some of these systemic fl aws exist beyond the Shuttle lieves that some of these systemic fl aws exist beyond the Shuttle lieves that some of these systemic fl aws exist beyond the Shuttle lieves that some of these systemic fl aws exist beyond the Shuttle lieves that some of these systemic fl aws exist beyond the Shuttle lieves that some of these systemic fl aws exist beyond the Shuttle lieves that some of these systemic fl aws exist beyond the Shuttle lieves that some of these systemic fl aws exist beyond the Shuttle Program. It was our determination that nearly half of the CAIB Program. It was our determination that nearly half of the CAIB Program. It was our determination that nearly half of the CAIB Program. It was our determination that nearly half of the CAIB Program. It was our determination that nearly half of the CAIB Program. It was our determination that nearly half of the CAIB Program. It was our determination that nearly half of the CAIB Program. It was our determination that nearly half of the CAIB Program. It was our determination that nearly half of the CAIB Program. It was our determination that nearly half of the CAIB Program. It was our determination that nearly half of the CAIB Program. It was our determination that nearly half of the CAIB R-O-Fs have bearing throughout the Agency. R-O-Fs have bearing throughout the Agency. R-O-Fs have bearing throughout the Agency. R-O-Fs have bearing throughout the Agency. R-O-Fs have bearing throughout the Agency. R-O-Fs have bearing throughout the Agency. R-O-Fs have bearing throughout the Agency. R-O-Fs have bearing throughout the Agency. R-O-Fs have bearing throughout the Agency. R-O-Fs have bearing throughout the Agency.

All the selected R-O-Fs were compiled and analyzed in what All the selected R-O-Fs were compiled and analyzed in what All the selected R-O-Fs were compiled and analyzed in what All the selected R-O-Fs were compiled and analyzed in what All the selected R-O-Fs were compiled and analyzed in what All the selected R-O-Fs were compiled and analyzed in what All the selected R-O-Fs were compiled and analyzed in what All the selected R-O-Fs were compiled and analyzed in what All the selected R-O-Fs were compiled and analyzed in what All the selected R-O-Fs were compiled and analyzed in what All the selected R-O-Fs were compiled and analyzed in what All the selected R-O-Fs were compiled and analyzed in what All the selected R-O-Fs were compiled and analyzed in what the Team called the CAIB Agency-wide Action Matrix, or Diaz the Team called the CAIB Agency-wide Action Matrix, or Diaz the Team called the CAIB Agency-wide Action Matrix, or Diaz the Team called the CAIB Agency-wide Action Matrix, or Diaz the Team called the CAIB Agency-wide Action Matrix, or Diaz the Team called the CAIB Agency-wide Action Matrix, or Diaz the Team called the CAIB Agency-wide Action Matrix, or Diaz the Team called the CAIB Agency-wide Action Matrix, or Diaz the Team called the CAIB Agency-wide Action Matrix, or Diaz the Team called the CAIB Agency-wide Action Matrix, or Diaz the Team called the CAIB Agency-wide Action Matrix, or Diaz the Team called the CAIB Agency-wide Action Matrix, or Diaz Team Matrix. We felt it was very important to release an early Team Matrix. We felt it was very important to release an early Team Matrix. We felt it was very important to release an early Team Matrix. We felt it was very important to release an early Team Matrix. We felt it was very important to release an early Team Matrix. We felt it was very important to release an early Team Matrix. We felt it was very important to release an early Team Matrix. We felt it was very important to release an early Team Matrix. We felt it was very important to release an early Team Matrix. We felt it was very important to release an early Team Matrix. We felt it was very important to release an early Team Matrix. We felt it was very important to release an early draft of the matrix to facilitate discussions within NASA. In draft of the matrix to facilitate discussions within NASA. In draft of the matrix to facilitate discussions within NASA. In draft of the matrix to facilitate discussions within NASA. In draft of the matrix to facilitate discussions within NASA. In draft of the matrix to facilitate discussions within NASA. In draft of the matrix to facilitate discussions within NASA. In draft of the matrix to facilitate discussions within NASA. In draft of the matrix to facilitate discussions within NASA. In draft of the matrix to facilitate discussions within NASA. In draft of the matrix to facilitate discussions within NASA. In draft of the matrix to facilitate discussions within NASA. In response, there were many inputs from NASA employees and response, there were many inputs from NASA employees and response, there were many inputs from NASA employees and response, there were many inputs from NASA employees and response, there were many inputs from NASA employees and response, there were many inputs from NASA employees and response, there were many inputs from NASA employees and response, there were many inputs from NASA employees and response, there were many inputs from NASA employees and response, there were many inputs from NASA employees and response, there were many inputs from NASA employees and response, there were many inputs from NASA employees and contractors during Safety and Mission Success Week, November contractors during Safety and Mission Success Week, November contractors during Safety and Mission Success Week, November contractors during Safety and Mission Success Week, November contractors during Safety and Mission Success Week, November contractors during Safety and Mission Success Week, November contractors during Safety and Mission Success Week, November contractors during Safety and Mission Success Week, November contractors during Safety and Mission Success Week, November contractors during Safety and Mission Success Week, November contractors during Safety and Mission Success Week, November contractors during Safety and Mission Success Week, November contractors during Safety and Mission Success Week, November 17 – 21, 2003. The message from this activity is clear. Individu-17 – 21, 2003. The message from this activity is clear. Individu-17 – 21, 2003. The message from this activity is clear. Individu-17 – 21, 2003. The message from this activity is clear. Individu-17 – 21, 2003. The message from this activity is clear. Individu-17 – 21, 2003. The message from this activity is clear. Individu-17 – 21, 2003. The message from this activity is clear. Individu-17 – 21, 2003. The message from this activity is clear. Individu-17 – 21, 2003. The message from this activity is clear. Individu-17 – 21, 2003. The message from this activity is clear. Individu-17 – 21, 2003. The message from this activity is clear. Individu-als in the NASA workforce state that some of the same practices als in the NASA workforce state that some of the same practices als in the NASA workforce state that some of the same practices als in the NASA workforce state that some of the same practices als in the NASA workforce state that some of the same practices als in the NASA workforce state that some of the same practices als in the NASA workforce state that some of the same practices als in the NASA workforce state that some of the same practices als in the NASA workforce state that some of the same practices als in the NASA workforce state that some of the same practices als in the NASA workforce state that some of the same practices als in the NASA workforce state that some of the same practices als in the NASA workforce state that some of the same practices identifi ed by the CAIB are evident throughout the Agency.identifi ed by the CAIB are evident throughout the Agency.identifi ed by the CAIB are evident throughout the Agency.identifi ed by the CAIB are evident throughout the Agency.identifi ed by the CAIB are evident throughout the Agency.identifi ed by the CAIB are evident throughout the Agency.identifi ed by the CAIB are evident throughout the Agency.identifi ed by the CAIB are evident throughout the Agency.identifi ed by the CAIB are evident throughout the Agency.identifi ed by the CAIB are evident throughout the Agency.identifi ed by the CAIB are evident throughout the Agency.

If NASA is to avoid another day like February 1, 2003, we must If NASA is to avoid another day like February 1, 2003, we must If NASA is to avoid another day like February 1, 2003, we must If NASA is to avoid another day like February 1, 2003, we must If NASA is to avoid another day like February 1, 2003, we must If NASA is to avoid another day like February 1, 2003, we must If NASA is to avoid another day like February 1, 2003, we must If NASA is to avoid another day like February 1, 2003, we must If NASA is to avoid another day like February 1, 2003, we must If NASA is to avoid another day like February 1, 2003, we must If NASA is to avoid another day like February 1, 2003, we must If NASA is to avoid another day like February 1, 2003, we must meet our mission objectives safely and renew our commitment meet our mission objectives safely and renew our commitment meet our mission objectives safely and renew our commitment meet our mission objectives safely and renew our commitment meet our mission objectives safely and renew our commitment meet our mission objectives safely and renew our commitment meet our mission objectives safely and renew our commitment meet our mission objectives safely and renew our commitment meet our mission objectives safely and renew our commitment meet our mission objectives safely and renew our commitment meet our mission objectives safely and renew our commitment meet our mission objectives safely and renew our commitment to excellence. In order to do this, we must identify corrective to excellence. In order to do this, we must identify corrective to excellence. In order to do this, we must identify corrective to excellence. In order to do this, we must identify corrective to excellence. In order to do this, we must identify corrective to excellence. In order to do this, we must identify corrective to excellence. In order to do this, we must identify corrective to excellence. In order to do this, we must identify corrective to excellence. In order to do this, we must identify corrective to excellence. In order to do this, we must identify corrective to excellence. In order to do this, we must identify corrective to excellence. In order to do this, we must identify corrective to excellence. In order to do this, we must identify corrective actions for each of the causes of the accident, and then imple-actions for each of the causes of the accident, and then imple-actions for each of the causes of the accident, and then imple-actions for each of the causes of the accident, and then imple-actions for each of the causes of the accident, and then imple-actions for each of the causes of the accident, and then imple-actions for each of the causes of the accident, and then imple-actions for each of the causes of the accident, and then imple-actions for each of the causes of the accident, and then imple-actions for each of the causes of the accident, and then imple-actions for each of the causes of the accident, and then imple-actions for each of the causes of the accident, and then imple-ment them fully and effectively. The CAIB Report should serve ment them fully and effectively. The CAIB Report should serve ment them fully and effectively. The CAIB Report should serve ment them fully and effectively. The CAIB Report should serve ment them fully and effectively. The CAIB Report should serve ment them fully and effectively. The CAIB Report should serve ment them fully and effectively. The CAIB Report should serve ment them fully and effectively. The CAIB Report should serve ment them fully and effectively. The CAIB Report should serve ment them fully and effectively. The CAIB Report should serve ment them fully and effectively. The CAIB Report should serve ment them fully and effectively. The CAIB Report should serve ment them fully and effectively. The CAIB Report should serve as a catalyst for change in the way all of us perform our work. It as a catalyst for change in the way all of us perform our work. It as a catalyst for change in the way all of us perform our work. It as a catalyst for change in the way all of us perform our work. It as a catalyst for change in the way all of us perform our work. It as a catalyst for change in the way all of us perform our work. It as a catalyst for change in the way all of us perform our work. It as a catalyst for change in the way all of us perform our work. It as a catalyst for change in the way all of us perform our work. It as a catalyst for change in the way all of us perform our work. It as a catalyst for change in the way all of us perform our work. It as a catalyst for change in the way all of us perform our work. It should prompt a renewed understanding of our shared purpose. should prompt a renewed understanding of our shared purpose. should prompt a renewed understanding of our shared purpose. should prompt a renewed understanding of our shared purpose. should prompt a renewed understanding of our shared purpose. should prompt a renewed understanding of our shared purpose. should prompt a renewed understanding of our shared purpose. should prompt a renewed understanding of our shared purpose. should prompt a renewed understanding of our shared purpose. should prompt a renewed understanding of our shared purpose. should prompt a renewed understanding of our shared purpose. should prompt a renewed understanding of our shared purpose. should prompt a renewed understanding of our shared purpose. Each member of this Team has recognized these high stakes and Each member of this Team has recognized these high stakes and Each member of this Team has recognized these high stakes and Each member of this Team has recognized these high stakes and Each member of this Team has recognized these high stakes and Each member of this Team has recognized these high stakes and Each member of this Team has recognized these high stakes and Each member of this Team has recognized these high stakes and Each member of this Team has recognized these high stakes and Each member of this Team has recognized these high stakes and Each member of this Team has recognized these high stakes and Each member of this Team has recognized these high stakes and has dedicated his or her efforts to that end. The signatures on has dedicated his or her efforts to that end. The signatures on has dedicated his or her efforts to that end. The signatures on has dedicated his or her efforts to that end. The signatures on has dedicated his or her efforts to that end. The signatures on has dedicated his or her efforts to that end. The signatures on has dedicated his or her efforts to that end. The signatures on has dedicated his or her efforts to that end. The signatures on has dedicated his or her efforts to that end. The signatures on has dedicated his or her efforts to that end. The signatures on has dedicated his or her efforts to that end. The signatures on has dedicated his or her efforts to that end. The signatures on has dedicated his or her efforts to that end. The signatures on this Report and the participation of each member of the NASA this Report and the participation of each member of the NASA this Report and the participation of each member of the NASA this Report and the participation of each member of the NASA this Report and the participation of each member of the NASA this Report and the participation of each member of the NASA this Report and the participation of each member of the NASA this Report and the participation of each member of the NASA this Report and the participation of each member of the NASA this Report and the participation of each member of the NASA this Report and the participation of each member of the NASA this Report and the participation of each member of the NASA leadership team at NASA Headquarters as well as at each of the leadership team at NASA Headquarters as well as at each of the leadership team at NASA Headquarters as well as at each of the leadership team at NASA Headquarters as well as at each of the leadership team at NASA Headquarters as well as at each of the leadership team at NASA Headquarters as well as at each of the leadership team at NASA Headquarters as well as at each of the leadership team at NASA Headquarters as well as at each of the leadership team at NASA Headquarters as well as at each of the leadership team at NASA Headquarters as well as at each of the leadership team at NASA Headquarters as well as at each of the leadership team at NASA Headquarters as well as at each of the NASA fi eld Centers are a refl ection of our joint commitment to NASA fi eld Centers are a refl ection of our joint commitment to NASA fi eld Centers are a refl ection of our joint commitment to NASA fi eld Centers are a refl ection of our joint commitment to NASA fi eld Centers are a refl ection of our joint commitment to NASA fi eld Centers are a refl ection of our joint commitment to NASA fi eld Centers are a refl ection of our joint commitment to NASA fi eld Centers are a refl ection of our joint commitment to NASA fi eld Centers are a refl ection of our joint commitment to NASA fi eld Centers are a refl ection of our joint commitment to NASA fi eld Centers are a refl ection of our joint commitment to NASA fi eld Centers are a refl ection of our joint commitment to NASA fi eld Centers are a refl ection of our joint commitment to NASA̓ s future.NASA̓ s future.NASA̓ s future.NASA̓ s future.

Dr. Ghassem AsrarDr. Ghassem AsrarDr. Ghassem AsrarDr. Ghassem AsrarDr. Ghassem AsrarAssociate AdministratorAssociate AdministratorAssociate AdministratorAssociate AdministratorAssociate Administrator

for Earth Sciencefor Earth Sciencefor Earth Sciencefor Earth ScienceNASA HeadquartersNASA HeadquartersNASA HeadquartersNASA HeadquartersNASA Headquarters

Mr. Scott HubbardMr. Scott HubbardMr. Scott HubbardMr. Scott HubbardDirector,Director,

Ames Research CenterAmes Research CenterAmes Research CenterAmes Research CenterAmes Research CenterAmes Research Center

Mr. Jim KennedyMr. Jim KennedyMr. Jim KennedyMr. Jim KennedyDirector,Director,

Kennedy Space CenterKennedy Space CenterKennedy Space CenterKennedy Space CenterKennedy Space CenterKennedy Space Center

Dr. Julian EarlsDr. Julian EarlsDr. Julian EarlsDr. Julian EarlsDirector,Director,

Glenn Research CenterGlenn Research CenterGlenn Research CenterGlenn Research CenterGlenn Research CenterGlenn Research Center

Ms. Vicki NovakMs. Vicki NovakMs. Vicki NovakMs. Vicki NovakAssistant AdministratorAssistant AdministratorAssistant AdministratorAssistant Administratorfor Human Resourcesfor Human Resourcesfor Human Resourcesfor Human Resourcesfor Human ResourcesNASA HeadquartersNASA HeadquartersNASA HeadquartersNASA Headquarters

PREFACE

Mr. Al DiazMr. Al DiazMr. Al DiazMr. Al DiazDirector, Goddard Director, Goddard Director, Goddard Director, Goddard

Space Flight CenterSpace Flight CenterSpace Flight CenterSpace Flight CenterSpace Flight Centerand Team Leadand Team Leadand Team Leadand Team Lead

2

ACKNOWLEDGEMENTSACKNOWLEDGEMENTSACKNOWLEDGEMENTSACKNOWLEDGEMENTSACKNOWLEDGEMENTS

The Diaz Team would like to thank each Center Director and each NASA Head-The Diaz Team would like to thank each Center Director and each NASA Head-The Diaz Team would like to thank each Center Director and each NASA Head-The Diaz Team would like to thank each Center Director and each NASA Head-The Diaz Team would like to thank each Center Director and each NASA Head-The Diaz Team would like to thank each Center Director and each NASA Head-The Diaz Team would like to thank each Center Director and each NASA Head-The Diaz Team would like to thank each Center Director and each NASA Head-The Diaz Team would like to thank each Center Director and each NASA Head-The Diaz Team would like to thank each Center Director and each NASA Head-The Diaz Team would like to thank each Center Director and each NASA Head-The Diaz Team would like to thank each Center Director and each NASA Head-The Diaz Team would like to thank each Center Director and each NASA Head-The Diaz Team would like to thank each Center Director and each NASA Head-quarters Associate and Assistant Administrator and their staff for their support and quarters Associate and Assistant Administrator and their staff for their support and quarters Associate and Assistant Administrator and their staff for their support and quarters Associate and Assistant Administrator and their staff for their support and quarters Associate and Assistant Administrator and their staff for their support and quarters Associate and Assistant Administrator and their staff for their support and quarters Associate and Assistant Administrator and their staff for their support and quarters Associate and Assistant Administrator and their staff for their support and quarters Associate and Assistant Administrator and their staff for their support and quarters Associate and Assistant Administrator and their staff for their support and quarters Associate and Assistant Administrator and their staff for their support and quarters Associate and Assistant Administrator and their staff for their support and quarters Associate and Assistant Administrator and their staff for their support and quarters Associate and Assistant Administrator and their staff for their support and quarters Associate and Assistant Administrator and their staff for their support and valuable feedback. In addition, our sincere thanks go to each NASA employee and valuable feedback. In addition, our sincere thanks go to each NASA employee and valuable feedback. In addition, our sincere thanks go to each NASA employee and valuable feedback. In addition, our sincere thanks go to each NASA employee and valuable feedback. In addition, our sincere thanks go to each NASA employee and valuable feedback. In addition, our sincere thanks go to each NASA employee and valuable feedback. In addition, our sincere thanks go to each NASA employee and valuable feedback. In addition, our sincere thanks go to each NASA employee and valuable feedback. In addition, our sincere thanks go to each NASA employee and valuable feedback. In addition, our sincere thanks go to each NASA employee and valuable feedback. In addition, our sincere thanks go to each NASA employee and valuable feedback. In addition, our sincere thanks go to each NASA employee and valuable feedback. In addition, our sincere thanks go to each NASA employee and valuable feedback. In addition, our sincere thanks go to each NASA employee and contractor who participated in discussions and provided their insights especially contractor who participated in discussions and provided their insights especially contractor who participated in discussions and provided their insights especially contractor who participated in discussions and provided their insights especially contractor who participated in discussions and provided their insights especially contractor who participated in discussions and provided their insights especially contractor who participated in discussions and provided their insights especially contractor who participated in discussions and provided their insights especially contractor who participated in discussions and provided their insights especially contractor who participated in discussions and provided their insights especially contractor who participated in discussions and provided their insights especially contractor who participated in discussions and provided their insights especially contractor who participated in discussions and provided their insights especially contractor who participated in discussions and provided their insights especially contractor who participated in discussions and provided their insights especially through participation in Safety and Mission Success Week, November 17 – 21, through participation in Safety and Mission Success Week, November 17 – 21, through participation in Safety and Mission Success Week, November 17 – 21, through participation in Safety and Mission Success Week, November 17 – 21, through participation in Safety and Mission Success Week, November 17 – 21, through participation in Safety and Mission Success Week, November 17 – 21, through participation in Safety and Mission Success Week, November 17 – 21, through participation in Safety and Mission Success Week, November 17 – 21, through participation in Safety and Mission Success Week, November 17 – 21, through participation in Safety and Mission Success Week, November 17 – 21, through participation in Safety and Mission Success Week, November 17 – 21, through participation in Safety and Mission Success Week, November 17 – 21, through participation in Safety and Mission Success Week, November 17 – 21, through participation in Safety and Mission Success Week, November 17 – 21, 2003. Those contributions were of great value, and they have been incorporated 2003. Those contributions were of great value, and they have been incorporated 2003. Those contributions were of great value, and they have been incorporated 2003. Those contributions were of great value, and they have been incorporated 2003. Those contributions were of great value, and they have been incorporated 2003. Those contributions were of great value, and they have been incorporated 2003. Those contributions were of great value, and they have been incorporated 2003. Those contributions were of great value, and they have been incorporated 2003. Those contributions were of great value, and they have been incorporated 2003. Those contributions were of great value, and they have been incorporated 2003. Those contributions were of great value, and they have been incorporated 2003. Those contributions were of great value, and they have been incorporated 2003. Those contributions were of great value, and they have been incorporated 2003. Those contributions were of great value, and they have been incorporated into this fi nal Report. In that respect, therefore, this is their Report, as well as into this fi nal Report. In that respect, therefore, this is their Report, as well as into this fi nal Report. In that respect, therefore, this is their Report, as well as into this fi nal Report. In that respect, therefore, this is their Report, as well as into this fi nal Report. In that respect, therefore, this is their Report, as well as into this fi nal Report. In that respect, therefore, this is their Report, as well as into this fi nal Report. In that respect, therefore, this is their Report, as well as into this fi nal Report. In that respect, therefore, this is their Report, as well as into this fi nal Report. In that respect, therefore, this is their Report, as well as into this fi nal Report. In that respect, therefore, this is their Report, as well as into this fi nal Report. In that respect, therefore, this is their Report, as well as into this fi nal Report. In that respect, therefore, this is their Report, as well as into this fi nal Report. In that respect, therefore, this is their Report, as well as into this fi nal Report. In that respect, therefore, this is their Report, as well as into this fi nal Report. In that respect, therefore, this is their Report, as well as ours.ours.

We would like to give special acknowledgement to the One NASA Team led by We would like to give special acknowledgement to the One NASA Team led by We would like to give special acknowledgement to the One NASA Team led by We would like to give special acknowledgement to the One NASA Team led by We would like to give special acknowledgement to the One NASA Team led by We would like to give special acknowledgement to the One NASA Team led by We would like to give special acknowledgement to the One NASA Team led by We would like to give special acknowledgement to the One NASA Team led by We would like to give special acknowledgement to the One NASA Team led by We would like to give special acknowledgement to the One NASA Team led by We would like to give special acknowledgement to the One NASA Team led by We would like to give special acknowledgement to the One NASA Team led by We would like to give special acknowledgement to the One NASA Team led by We would like to give special acknowledgement to the One NASA Team led by Mr. Johnny Stephenson. Their energy and dedication to NASA was instrumental Mr. Johnny Stephenson. Their energy and dedication to NASA was instrumental Mr. Johnny Stephenson. Their energy and dedication to NASA was instrumental Mr. Johnny Stephenson. Their energy and dedication to NASA was instrumental Mr. Johnny Stephenson. Their energy and dedication to NASA was instrumental Mr. Johnny Stephenson. Their energy and dedication to NASA was instrumental Mr. Johnny Stephenson. Their energy and dedication to NASA was instrumental Mr. Johnny Stephenson. Their energy and dedication to NASA was instrumental Mr. Johnny Stephenson. Their energy and dedication to NASA was instrumental Mr. Johnny Stephenson. Their energy and dedication to NASA was instrumental Mr. Johnny Stephenson. Their energy and dedication to NASA was instrumental Mr. Johnny Stephenson. Their energy and dedication to NASA was instrumental Mr. Johnny Stephenson. Their energy and dedication to NASA was instrumental Mr. Johnny Stephenson. Their energy and dedication to NASA was instrumental Mr. Johnny Stephenson. Their energy and dedication to NASA was instrumental in achieving the success of Safety and Mission Success Week.in achieving the success of Safety and Mission Success Week.in achieving the success of Safety and Mission Success Week.in achieving the success of Safety and Mission Success Week.in achieving the success of Safety and Mission Success Week.in achieving the success of Safety and Mission Success Week.in achieving the success of Safety and Mission Success Week.in achieving the success of Safety and Mission Success Week.in achieving the success of Safety and Mission Success Week.in achieving the success of Safety and Mission Success Week.in achieving the success of Safety and Mission Success Week.

While it is diffi cult to acknowledge each individual that made a signifi cant con-While it is diffi cult to acknowledge each individual that made a signifi cant con-While it is diffi cult to acknowledge each individual that made a signifi cant con-While it is diffi cult to acknowledge each individual that made a signifi cant con-While it is diffi cult to acknowledge each individual that made a signifi cant con-While it is diffi cult to acknowledge each individual that made a signifi cant con-While it is diffi cult to acknowledge each individual that made a signifi cant con-While it is diffi cult to acknowledge each individual that made a signifi cant con-While it is diffi cult to acknowledge each individual that made a signifi cant con-While it is diffi cult to acknowledge each individual that made a signifi cant con-While it is diffi cult to acknowledge each individual that made a signifi cant con-While it is diffi cult to acknowledge each individual that made a signifi cant con-While it is diffi cult to acknowledge each individual that made a signifi cant con-While it is diffi cult to acknowledge each individual that made a signifi cant con-tribution to the development of this Report, there are two individuals that deserve tribution to the development of this Report, there are two individuals that deserve tribution to the development of this Report, there are two individuals that deserve tribution to the development of this Report, there are two individuals that deserve tribution to the development of this Report, there are two individuals that deserve tribution to the development of this Report, there are two individuals that deserve tribution to the development of this Report, there are two individuals that deserve tribution to the development of this Report, there are two individuals that deserve tribution to the development of this Report, there are two individuals that deserve tribution to the development of this Report, there are two individuals that deserve tribution to the development of this Report, there are two individuals that deserve tribution to the development of this Report, there are two individuals that deserve tribution to the development of this Report, there are two individuals that deserve tribution to the development of this Report, there are two individuals that deserve special recognition. The Team would like to thank Ms. Judy Bruner, Assistant special recognition. The Team would like to thank Ms. Judy Bruner, Assistant special recognition. The Team would like to thank Ms. Judy Bruner, Assistant special recognition. The Team would like to thank Ms. Judy Bruner, Assistant special recognition. The Team would like to thank Ms. Judy Bruner, Assistant special recognition. The Team would like to thank Ms. Judy Bruner, Assistant special recognition. The Team would like to thank Ms. Judy Bruner, Assistant special recognition. The Team would like to thank Ms. Judy Bruner, Assistant special recognition. The Team would like to thank Ms. Judy Bruner, Assistant special recognition. The Team would like to thank Ms. Judy Bruner, Assistant special recognition. The Team would like to thank Ms. Judy Bruner, Assistant special recognition. The Team would like to thank Ms. Judy Bruner, Assistant special recognition. The Team would like to thank Ms. Judy Bruner, Assistant special recognition. The Team would like to thank Ms. Judy Bruner, Assistant special recognition. The Team would like to thank Ms. Judy Bruner, Assistant Director for Safety and Security, NASA̓ s Goddard Space Flight Center, for Director for Safety and Security, NASA̓ s Goddard Space Flight Center, for Director for Safety and Security, NASA̓ s Goddard Space Flight Center, for Director for Safety and Security, NASA̓ s Goddard Space Flight Center, for Director for Safety and Security, NASA̓ s Goddard Space Flight Center, for Director for Safety and Security, NASA̓ s Goddard Space Flight Center, for Director for Safety and Security, NASA̓ s Goddard Space Flight Center, for Director for Safety and Security, NASA̓ s Goddard Space Flight Center, for Director for Safety and Security, NASA̓ s Goddard Space Flight Center, for Director for Safety and Security, NASA̓ s Goddard Space Flight Center, for Director for Safety and Security, NASA̓ s Goddard Space Flight Center, for Director for Safety and Security, NASA̓ s Goddard Space Flight Center, for Director for Safety and Security, NASA̓ s Goddard Space Flight Center, for Director for Safety and Security, NASA̓ s Goddard Space Flight Center, for her steadfast commitment and dedication to the successful development of this her steadfast commitment and dedication to the successful development of this her steadfast commitment and dedication to the successful development of this her steadfast commitment and dedication to the successful development of this her steadfast commitment and dedication to the successful development of this her steadfast commitment and dedication to the successful development of this her steadfast commitment and dedication to the successful development of this her steadfast commitment and dedication to the successful development of this her steadfast commitment and dedication to the successful development of this her steadfast commitment and dedication to the successful development of this her steadfast commitment and dedication to the successful development of this her steadfast commitment and dedication to the successful development of this her steadfast commitment and dedication to the successful development of this her steadfast commitment and dedication to the successful development of this her steadfast commitment and dedication to the successful development of this Report and for her personal contributions to its content. We would also like to Report and for her personal contributions to its content. We would also like to Report and for her personal contributions to its content. We would also like to Report and for her personal contributions to its content. We would also like to Report and for her personal contributions to its content. We would also like to Report and for her personal contributions to its content. We would also like to Report and for her personal contributions to its content. We would also like to Report and for her personal contributions to its content. We would also like to Report and for her personal contributions to its content. We would also like to Report and for her personal contributions to its content. We would also like to Report and for her personal contributions to its content. We would also like to Report and for her personal contributions to its content. We would also like to Report and for her personal contributions to its content. We would also like to Report and for her personal contributions to its content. We would also like to recognize the invaluable contributions of Mr. Kevin Mabie, Valador Inc., for his recognize the invaluable contributions of Mr. Kevin Mabie, Valador Inc., for his recognize the invaluable contributions of Mr. Kevin Mabie, Valador Inc., for his recognize the invaluable contributions of Mr. Kevin Mabie, Valador Inc., for his recognize the invaluable contributions of Mr. Kevin Mabie, Valador Inc., for his recognize the invaluable contributions of Mr. Kevin Mabie, Valador Inc., for his recognize the invaluable contributions of Mr. Kevin Mabie, Valador Inc., for his recognize the invaluable contributions of Mr. Kevin Mabie, Valador Inc., for his recognize the invaluable contributions of Mr. Kevin Mabie, Valador Inc., for his recognize the invaluable contributions of Mr. Kevin Mabie, Valador Inc., for his recognize the invaluable contributions of Mr. Kevin Mabie, Valador Inc., for his recognize the invaluable contributions of Mr. Kevin Mabie, Valador Inc., for his recognize the invaluable contributions of Mr. Kevin Mabie, Valador Inc., for his recognize the invaluable contributions of Mr. Kevin Mabie, Valador Inc., for his recognize the invaluable contributions of Mr. Kevin Mabie, Valador Inc., for his contributions both in writing as well as producing this Report.contributions both in writing as well as producing this Report.contributions both in writing as well as producing this Report.contributions both in writing as well as producing this Report.contributions both in writing as well as producing this Report.contributions both in writing as well as producing this Report.contributions both in writing as well as producing this Report.contributions both in writing as well as producing this Report.contributions both in writing as well as producing this Report.contributions both in writing as well as producing this Report.contributions both in writing as well as producing this Report.

DEDICATIONDEDICATIONDEDICATIONDEDICATION

The Diaz Team would like to dedicate this Report and the efforts involved in the The Diaz Team would like to dedicate this Report and the efforts involved in the The Diaz Team would like to dedicate this Report and the efforts involved in the The Diaz Team would like to dedicate this Report and the efforts involved in the The Diaz Team would like to dedicate this Report and the efforts involved in the The Diaz Team would like to dedicate this Report and the efforts involved in the The Diaz Team would like to dedicate this Report and the efforts involved in the The Diaz Team would like to dedicate this Report and the efforts involved in the The Diaz Team would like to dedicate this Report and the efforts involved in the The Diaz Team would like to dedicate this Report and the efforts involved in the The Diaz Team would like to dedicate this Report and the efforts involved in the The Diaz Team would like to dedicate this Report and the efforts involved in the The Diaz Team would like to dedicate this Report and the efforts involved in the The Diaz Team would like to dedicate this Report and the efforts involved in the The Diaz Team would like to dedicate this Report and the efforts involved in the development of it to the memory of the crew of the Space Shuttle development of it to the memory of the crew of the Space Shuttle development of it to the memory of the crew of the Space Shuttle development of it to the memory of the crew of the Space Shuttle development of it to the memory of the crew of the Space Shuttle development of it to the memory of the crew of the Space Shuttle development of it to the memory of the crew of the Space Shuttle development of it to the memory of the crew of the Space Shuttle development of it to the memory of the crew of the Space Shuttle development of it to the memory of the crew of the Space Shuttle development of it to the memory of the crew of the Space Shuttle development of it to the memory of the crew of the Space Shuttle ColumbiaColumbia. It . It was their bravery that inspired us to make a difference in NASA̓ s future on their was their bravery that inspired us to make a difference in NASA̓ s future on their was their bravery that inspired us to make a difference in NASA̓ s future on their was their bravery that inspired us to make a difference in NASA̓ s future on their was their bravery that inspired us to make a difference in NASA̓ s future on their was their bravery that inspired us to make a difference in NASA̓ s future on their was their bravery that inspired us to make a difference in NASA̓ s future on their was their bravery that inspired us to make a difference in NASA̓ s future on their was their bravery that inspired us to make a difference in NASA̓ s future on their was their bravery that inspired us to make a difference in NASA̓ s future on their was their bravery that inspired us to make a difference in NASA̓ s future on their was their bravery that inspired us to make a difference in NASA̓ s future on their was their bravery that inspired us to make a difference in NASA̓ s future on their was their bravery that inspired us to make a difference in NASA̓ s future on their was their bravery that inspired us to make a difference in NASA̓ s future on their behalf.behalf.

Mr. Al DiazMr. Al DiazMr. Al DiazMr. Al DiazDirector, Goddard Space Flight CenterDirector, Goddard Space Flight CenterDirector, Goddard Space Flight CenterDirector, Goddard Space Flight CenterDirector, Goddard Space Flight CenterDirector, Goddard Space Flight CenterDirector, Goddard Space Flight Centerand Team Leadand Team Leadand Team Lead

3

PrefacePrefacePrefacePreface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Acknowledgements and DedicationAcknowledgements and DedicationAcknowledgements and DedicationAcknowledgements and DedicationAcknowledgements and DedicationAcknowledgements and DedicationAcknowledgements and DedicationAcknowledgements and Dedication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

1.01.0 Executive SummaryExecutive SummaryExecutive SummaryExecutive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51.11.1 IntroductionIntroductionIntroductionIntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 551.2 LeadershipLeadershipLeadership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10101.31.3 Learning Learning Learning Learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1111111.4 Communication Communication Communication Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12121.5 Processes and Rules Processes and Rules Processes and Rules Processes and Rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13131.6 Technical Capabilities Technical Capabilities Technical Capabilities Technical Capabilities Technical Capabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14141.7 Organizational Structure Organizational Structure Organizational Structure Organizational Structure Organizational Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1151.81.8 Risk Management Risk Management Risk Management Risk Management Risk Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111661.9 SummarySummarySummary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17171.10 Next StepsNext StepsNext StepsNext Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1717

2.02.0 IntroductionIntroductionIntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19192.12.1 BackgroundBackgroundBackgroundBackground . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1919192.2 The Team and Its CharterThe Team and Its CharterThe Team and Its CharterThe Team and Its CharterThe Team and Its Charter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19192.32.3 R-O-F CategoriesR-O-F CategoriesR-O-F CategoriesR-O-F CategoriesR-O-F Categories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1919192.4 Team DiscussionsTeam DiscussionsTeam DiscussionsTeam Discussions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19192.5 Safety and Mission Success Week Safety and Mission Success Week Safety and Mission Success Week Safety and Mission Success Week Safety and Mission Success Week Safety and Mission Success Week Safety and Mission Success Week . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20202.62.6 Report LayoutReport LayoutReport LayoutReport Layout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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3.03.03.0 Leadership Leadership Leadership Leadership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2222223.1 IntroductionIntroductionIntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22223.2 Category R-O-F SummaryCategory R-O-F SummaryCategory R-O-F SummaryCategory R-O-F SummaryCategory R-O-F Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22223.3 DiscussionDiscussionDiscussionDiscussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2222

4.04.04.0 Learning Learning Learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2626264.1 IntroductionIntroductionIntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26264.2 Category R-O-F SummaryCategory R-O-F SummaryCategory R-O-F SummaryCategory R-O-F SummaryCategory R-O-F SummaryCategory R-O-F Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26264.3 DiscussionDiscussionDiscussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2626

5.05.05.0 Communication Communication Communication Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3030305.1 IntroductionIntroductionIntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30305.25.2 Category R-O-F SummaryCategory R-O-F SummaryCategory R-O-F SummaryCategory R-O-F SummaryCategory R-O-F SummaryCategory R-O-F Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3030305.3 DiscussionDiscussionDiscussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3030

6.06.06.0 Processes and Rules Processes and Rules Processes and Rules Processes and Rules Processes and Rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3434346.1 IntroductionIntroductionIntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34346.26.2 Category R-O-F SummaryCategory R-O-F SummaryCategory R-O-F SummaryCategory R-O-F SummaryCategory R-O-F SummaryCategory R-O-F Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3434346.3 DiscussionDiscussionDiscussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3434

7.07.07.0 Technical CapabilitiesTechnical CapabilitiesTechnical CapabilitiesTechnical CapabilitiesTechnical CapabilitiesTechnical Capabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3838387.1 IntroductionIntroductionIntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38387.27.2 Category R-O-F SummaryCategory R-O-F SummaryCategory R-O-F SummaryCategory R-O-F SummaryCategory R-O-F SummaryCategory R-O-F Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3838387.3 DiscussionDiscussionDiscussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3838

8.08.0 Organizational StructureOrganizational StructureOrganizational StructureOrganizational StructureOrganizational Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42428.1 IntroductionIntroductionIntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42428.28.2 Category R-O-F SummaryCategory R-O-F SummaryCategory R-O-F SummaryCategory R-O-F SummaryCategory R-O-F SummaryCategory R-O-F Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4242428.3 DiscussionDiscussionDiscussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4242

9.09.0 Risk Management Risk Management Risk Management Risk Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46469.1 IntroductionIntroductionIntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4469.29.2 Category R-O-F SummaryCategory R-O-F SummaryCategory R-O-F SummaryCategory R-O-F SummaryCategory R-O-F SummaryCategory R-O-F Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 444669.3 DiscussionDiscussionDiscussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 446

10.010.0 Summary and Next StepsSummary and Next StepsSummary and Next StepsSummary and Next StepsSummary and Next Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 505010.1 SummarySummarySummary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50501010.2.2 Next StepsNext StepsNext StepsNext Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-1A-1A-1

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

Appendix BAppendix BAppendix BAppendix B AcronymsAcronymsAcronymsAcronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-1B-1

4

List of TablesList of TablesList of TablesList of Tables

Table 1. Table 1. Table 1. Table 1. The Physical Cause and Organizational Cause of the Columbia accident as determined by the CAIB.The Physical Cause and Organizational Cause of the Columbia accident as determined by the CAIB.The Physical Cause and Organizational Cause of the Columbia accident as determined by the CAIB.The Physical Cause and Organizational Cause of the Columbia accident as determined by the CAIB.The Physical Cause and Organizational Cause of the Columbia accident as determined by the CAIB.The Physical Cause and Organizational Cause of the Columbia accident as determined by the CAIB.The Physical Cause and Organizational Cause of the Columbia accident as determined by the CAIB.The Physical Cause and Organizational Cause of the Columbia accident as determined by the CAIB.The Physical Cause and Organizational Cause of the Columbia accident as determined by the CAIB.The Physical Cause and Organizational Cause of the Columbia accident as determined by the CAIB.The Physical Cause and Organizational Cause of the Columbia accident as determined by the CAIB.The Physical Cause and Organizational Cause of the Columbia accident as determined by the CAIB.The Physical Cause and Organizational Cause of the Columbia accident as determined by the CAIB.The Physical Cause and Organizational Cause of the Columbia accident as determined by the CAIB.The Physical Cause and Organizational Cause of the Columbia accident as determined by the CAIB.The Physical Cause and Organizational Cause of the Columbia accident as determined by the CAIB.The Physical Cause and Organizational Cause of the Columbia accident as determined by the CAIB.The Physical Cause and Organizational Cause of the Columbia accident as determined by the CAIB. . . . . . . . . . . . . . . . . . . . . . 55Table 2. Table 2. Table 2. The Diaz Team developed one goal for Leadership.The Diaz Team developed one goal for Leadership.The Diaz Team developed one goal for Leadership.The Diaz Team developed one goal for Leadership.The Diaz Team developed one goal for Leadership.The Diaz Team developed one goal for Leadership.The Diaz Team developed one goal for Leadership.The Diaz Team developed one goal for Leadership.The Diaz Team developed one goal for Leadership. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1010Table 3. Table 3. Table 3. Table 3. The Diaz Team developed one goal for Learning.The Diaz Team developed one goal for Learning.The Diaz Team developed one goal for Learning.The Diaz Team developed one goal for Learning.The Diaz Team developed one goal for Learning.The Diaz Team developed one goal for Learning.The Diaz Team developed one goal for Learning.The Diaz Team developed one goal for Learning.The Diaz Team developed one goal for Learning.The Diaz Team developed one goal for Learning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11111Table 4. Table 4. Table 4. The Diaz Team developed one goal for Communication.The Diaz Team developed one goal for Communication.The Diaz Team developed one goal for Communication.The Diaz Team developed one goal for Communication.The Diaz Team developed one goal for Communication.The Diaz Team developed one goal for Communication.The Diaz Team developed one goal for Communication.The Diaz Team developed one goal for Communication.The Diaz Team developed one goal for Communication.The Diaz Team developed one goal for Communication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Table 5. Table 5. Table 5. The Diaz Team developed one goal for Processes and Rules.The Diaz Team developed one goal for Processes and Rules.The Diaz Team developed one goal for Processes and Rules.The Diaz Team developed one goal for Processes and Rules.The Diaz Team developed one goal for Processes and Rules.The Diaz Team developed one goal for Processes and Rules.The Diaz Team developed one goal for Processes and Rules.The Diaz Team developed one goal for Processes and Rules.The Diaz Team developed one goal for Processes and Rules.The Diaz Team developed one goal for Processes and Rules.The Diaz Team developed one goal for Processes and Rules.The Diaz Team developed one goal for Processes and Rules. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Table 6. Table 6. Table 6. The Diaz Team developed one goal for Technical Capabilities.The Diaz Team developed one goal for Technical Capabilities.The Diaz Team developed one goal for Technical Capabilities.The Diaz Team developed one goal for Technical Capabilities.The Diaz Team developed one goal for Technical Capabilities.The Diaz Team developed one goal for Technical Capabilities.The Diaz Team developed one goal for Technical Capabilities.The Diaz Team developed one goal for Technical Capabilities.The Diaz Team developed one goal for Technical Capabilities.The Diaz Team developed one goal for Technical Capabilities.The Diaz Team developed one goal for Technical Capabilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Table 7. Table 7. Table 7. The Diaz Team developed one goal for Organizational Structure.The Diaz Team developed one goal for Organizational Structure.The Diaz Team developed one goal for Organizational Structure.The Diaz Team developed one goal for Organizational Structure.The Diaz Team developed one goal for Organizational Structure.The Diaz Team developed one goal for Organizational Structure.The Diaz Team developed one goal for Organizational Structure.The Diaz Team developed one goal for Organizational Structure.The Diaz Team developed one goal for Organizational Structure.The Diaz Team developed one goal for Organizational Structure.The Diaz Team developed one goal for Organizational Structure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Table 8. Table 8. Table 8. Table 8. The Diaz Team developed one goal for Risk Management.The Diaz Team developed one goal for Risk Management.The Diaz Team developed one goal for Risk Management.The Diaz Team developed one goal for Risk Management.The Diaz Team developed one goal for Risk Management.The Diaz Team developed one goal for Risk Management.The Diaz Team developed one goal for Risk Management.The Diaz Team developed one goal for Risk Management.The Diaz Team developed one goal for Risk Management.The Diaz Team developed one goal for Risk Management.The Diaz Team developed one goal for Risk Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166Table 9. Table 9. Table 9. Organizing the R-O-Fs – the seven categories and their defi nitions. Organizing the R-O-Fs – the seven categories and their defi nitions. Organizing the R-O-Fs – the seven categories and their defi nitions. Organizing the R-O-Fs – the seven categories and their defi nitions. Organizing the R-O-Fs – the seven categories and their defi nitions. Organizing the R-O-Fs – the seven categories and their defi nitions. Organizing the R-O-Fs – the seven categories and their defi nitions. Organizing the R-O-Fs – the seven categories and their defi nitions. Organizing the R-O-Fs – the seven categories and their defi nitions. Organizing the R-O-Fs – the seven categories and their defi nitions. Organizing the R-O-Fs – the seven categories and their defi nitions. Organizing the R-O-Fs – the seven categories and their defi nitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2020Table 10. Table 10. Table 10. Table 10. The Diaz Team developed one goal for Leadership.The Diaz Team developed one goal for Leadership.The Diaz Team developed one goal for Leadership.The Diaz Team developed one goal for Leadership.The Diaz Team developed one goal for Leadership.The Diaz Team developed one goal for Leadership.The Diaz Team developed one goal for Leadership.The Diaz Team developed one goal for Leadership.The Diaz Team developed one goal for Leadership.The Diaz Team developed one goal for Leadership. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242424Table 11. Table 11. Table 11. The Diaz Team determined that three Observations, and 14 Findings could be included The Diaz Team determined that three Observations, and 14 Findings could be included The Diaz Team determined that three Observations, and 14 Findings could be included The Diaz Team determined that three Observations, and 14 Findings could be included The Diaz Team determined that three Observations, and 14 Findings could be included The Diaz Team determined that three Observations, and 14 Findings could be included The Diaz Team determined that three Observations, and 14 Findings could be included The Diaz Team determined that three Observations, and 14 Findings could be included The Diaz Team determined that three Observations, and 14 Findings could be included The Diaz Team determined that three Observations, and 14 Findings could be included The Diaz Team determined that three Observations, and 14 Findings could be included The Diaz Team determined that three Observations, and 14 Findings could be included The Diaz Team determined that three Observations, and 14 Findings could be included The Diaz Team determined that three Observations, and 14 Findings could be included The Diaz Team determined that three Observations, and 14 Findings could be included

in the Leadership Category resulting in seven actions.in the Leadership Category resulting in seven actions.in the Leadership Category resulting in seven actions.in the Leadership Category resulting in seven actions.in the Leadership Category resulting in seven actions.in the Leadership Category resulting in seven actions.in the Leadership Category resulting in seven actions.in the Leadership Category resulting in seven actions.in the Leadership Category resulting in seven actions.in the Leadership Category resulting in seven actions.in the Leadership Category resulting in seven actions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22255Table 12. Table 12. Table 12. The Diaz Team developed one goal for Learning.The Diaz Team developed one goal for Learning.The Diaz Team developed one goal for Learning.The Diaz Team developed one goal for Learning.The Diaz Team developed one goal for Learning.The Diaz Team developed one goal for Learning.The Diaz Team developed one goal for Learning.The Diaz Team developed one goal for Learning.The Diaz Team developed one goal for Learning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2828Table 13. Table 13. Table 13. The Diaz Team determined that one Recommendation and four Findings could be included The Diaz Team determined that one Recommendation and four Findings could be included The Diaz Team determined that one Recommendation and four Findings could be included The Diaz Team determined that one Recommendation and four Findings could be included The Diaz Team determined that one Recommendation and four Findings could be included The Diaz Team determined that one Recommendation and four Findings could be included The Diaz Team determined that one Recommendation and four Findings could be included The Diaz Team determined that one Recommendation and four Findings could be included The Diaz Team determined that one Recommendation and four Findings could be included The Diaz Team determined that one Recommendation and four Findings could be included The Diaz Team determined that one Recommendation and four Findings could be included The Diaz Team determined that one Recommendation and four Findings could be included The Diaz Team determined that one Recommendation and four Findings could be included The Diaz Team determined that one Recommendation and four Findings could be included The Diaz Team determined that one Recommendation and four Findings could be included The Diaz Team determined that one Recommendation and four Findings could be included The Diaz Team determined that one Recommendation and four Findings could be included

in the Learning Category resulting in three actions.in the Learning Category resulting in three actions.in the Learning Category resulting in three actions.in the Learning Category resulting in three actions.in the Learning Category resulting in three actions.in the Learning Category resulting in three actions.in the Learning Category resulting in three actions.in the Learning Category resulting in three actions.in the Learning Category resulting in three actions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2929Table 14. Table 14. Table 14. The Diaz Team developed one goal for Communication.The Diaz Team developed one goal for Communication.The Diaz Team developed one goal for Communication.The Diaz Team developed one goal for Communication.The Diaz Team developed one goal for Communication.The Diaz Team developed one goal for Communication.The Diaz Team developed one goal for Communication.The Diaz Team developed one goal for Communication.The Diaz Team developed one goal for Communication.The Diaz Team developed one goal for Communication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 332Table 15. Table 15. Table 15. Table 15. The Diaz Team determined that fi ve Findings could be included in the Communication Category The Diaz Team determined that fi ve Findings could be included in the Communication Category The Diaz Team determined that fi ve Findings could be included in the Communication Category The Diaz Team determined that fi ve Findings could be included in the Communication Category The Diaz Team determined that fi ve Findings could be included in the Communication Category The Diaz Team determined that fi ve Findings could be included in the Communication Category The Diaz Team determined that fi ve Findings could be included in the Communication Category The Diaz Team determined that fi ve Findings could be included in the Communication Category The Diaz Team determined that fi ve Findings could be included in the Communication Category The Diaz Team determined that fi ve Findings could be included in the Communication Category The Diaz Team determined that fi ve Findings could be included in the Communication Category The Diaz Team determined that fi ve Findings could be included in the Communication Category The Diaz Team determined that fi ve Findings could be included in the Communication Category The Diaz Team determined that fi ve Findings could be included in the Communication Category The Diaz Team determined that fi ve Findings could be included in the Communication Category The Diaz Team determined that fi ve Findings could be included in the Communication Category The Diaz Team determined that fi ve Findings could be included in the Communication Category The Diaz Team determined that fi ve Findings could be included in the Communication Category

resulting in two actions. resulting in two actions. resulting in two actions. resulting in two actions. resulting in two actions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 332Table 16. Table 16. Table 16. Table 16. The Diaz Team developed one goal for Processes and Rules.The Diaz Team developed one goal for Processes and Rules.The Diaz Team developed one goal for Processes and Rules.The Diaz Team developed one goal for Processes and Rules.The Diaz Team developed one goal for Processes and Rules.The Diaz Team developed one goal for Processes and Rules.The Diaz Team developed one goal for Processes and Rules.The Diaz Team developed one goal for Processes and Rules.The Diaz Team developed one goal for Processes and Rules.The Diaz Team developed one goal for Processes and Rules.The Diaz Team developed one goal for Processes and Rules.The Diaz Team developed one goal for Processes and Rules. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33366Table 17. Table 17. Table 17. The Diaz Team determined that two Recommendations, three Observations, and six Findings The Diaz Team determined that two Recommendations, three Observations, and six Findings The Diaz Team determined that two Recommendations, three Observations, and six Findings The Diaz Team determined that two Recommendations, three Observations, and six Findings The Diaz Team determined that two Recommendations, three Observations, and six Findings The Diaz Team determined that two Recommendations, three Observations, and six Findings The Diaz Team determined that two Recommendations, three Observations, and six Findings The Diaz Team determined that two Recommendations, three Observations, and six Findings The Diaz Team determined that two Recommendations, three Observations, and six Findings The Diaz Team determined that two Recommendations, three Observations, and six Findings The Diaz Team determined that two Recommendations, three Observations, and six Findings The Diaz Team determined that two Recommendations, three Observations, and six Findings The Diaz Team determined that two Recommendations, three Observations, and six Findings The Diaz Team determined that two Recommendations, three Observations, and six Findings The Diaz Team determined that two Recommendations, three Observations, and six Findings The Diaz Team determined that two Recommendations, three Observations, and six Findings

could be included in the Processes & Rules Category resulting in seven actions.could be included in the Processes & Rules Category resulting in seven actions.could be included in the Processes & Rules Category resulting in seven actions.could be included in the Processes & Rules Category resulting in seven actions.could be included in the Processes & Rules Category resulting in seven actions.could be included in the Processes & Rules Category resulting in seven actions.could be included in the Processes & Rules Category resulting in seven actions.could be included in the Processes & Rules Category resulting in seven actions.could be included in the Processes & Rules Category resulting in seven actions.could be included in the Processes & Rules Category resulting in seven actions.could be included in the Processes & Rules Category resulting in seven actions.could be included in the Processes & Rules Category resulting in seven actions.could be included in the Processes & Rules Category resulting in seven actions.could be included in the Processes & Rules Category resulting in seven actions.could be included in the Processes & Rules Category resulting in seven actions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363636Table 18. Table 18. Table 18. The Diaz Team developed one goal for Technical Capabilities.The Diaz Team developed one goal for Technical Capabilities.The Diaz Team developed one goal for Technical Capabilities.The Diaz Team developed one goal for Technical Capabilities.The Diaz Team developed one goal for Technical Capabilities.The Diaz Team developed one goal for Technical Capabilities.The Diaz Team developed one goal for Technical Capabilities.The Diaz Team developed one goal for Technical Capabilities.The Diaz Team developed one goal for Technical Capabilities.The Diaz Team developed one goal for Technical Capabilities.The Diaz Team developed one goal for Technical Capabilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4040Table 19. Table 19. Table 19. The Diaz Team determined that three Recommendations, and 13 Findings could be included The Diaz Team determined that three Recommendations, and 13 Findings could be included The Diaz Team determined that three Recommendations, and 13 Findings could be included The Diaz Team determined that three Recommendations, and 13 Findings could be included The Diaz Team determined that three Recommendations, and 13 Findings could be included The Diaz Team determined that three Recommendations, and 13 Findings could be included The Diaz Team determined that three Recommendations, and 13 Findings could be included The Diaz Team determined that three Recommendations, and 13 Findings could be included The Diaz Team determined that three Recommendations, and 13 Findings could be included The Diaz Team determined that three Recommendations, and 13 Findings could be included The Diaz Team determined that three Recommendations, and 13 Findings could be included The Diaz Team determined that three Recommendations, and 13 Findings could be included The Diaz Team determined that three Recommendations, and 13 Findings could be included The Diaz Team determined that three Recommendations, and 13 Findings could be included The Diaz Team determined that three Recommendations, and 13 Findings could be included The Diaz Team determined that three Recommendations, and 13 Findings could be included

in the Technical Capabilities Category resulting in six actions.in the Technical Capabilities Category resulting in six actions.in the Technical Capabilities Category resulting in six actions.in the Technical Capabilities Category resulting in six actions.in the Technical Capabilities Category resulting in six actions.in the Technical Capabilities Category resulting in six actions.in the Technical Capabilities Category resulting in six actions.in the Technical Capabilities Category resulting in six actions.in the Technical Capabilities Category resulting in six actions.in the Technical Capabilities Category resulting in six actions.in the Technical Capabilities Category resulting in six actions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4040Table 20. Table 20. Table 20. The Diaz Team developed one goal for Organizational Structure.The Diaz Team developed one goal for Organizational Structure.The Diaz Team developed one goal for Organizational Structure.The Diaz Team developed one goal for Organizational Structure.The Diaz Team developed one goal for Organizational Structure.The Diaz Team developed one goal for Organizational Structure.The Diaz Team developed one goal for Organizational Structure.The Diaz Team developed one goal for Organizational Structure.The Diaz Team developed one goal for Organizational Structure.The Diaz Team developed one goal for Organizational Structure.The Diaz Team developed one goal for Organizational Structure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 444Table 21. Table 21. Table 21. Table 21. The Diaz Team determined that three Recommendations and 10 Findings could be included The Diaz Team determined that three Recommendations and 10 Findings could be included The Diaz Team determined that three Recommendations and 10 Findings could be included The Diaz Team determined that three Recommendations and 10 Findings could be included The Diaz Team determined that three Recommendations and 10 Findings could be included The Diaz Team determined that three Recommendations and 10 Findings could be included The Diaz Team determined that three Recommendations and 10 Findings could be included The Diaz Team determined that three Recommendations and 10 Findings could be included The Diaz Team determined that three Recommendations and 10 Findings could be included The Diaz Team determined that three Recommendations and 10 Findings could be included The Diaz Team determined that three Recommendations and 10 Findings could be included The Diaz Team determined that three Recommendations and 10 Findings could be included The Diaz Team determined that three Recommendations and 10 Findings could be included The Diaz Team determined that three Recommendations and 10 Findings could be included The Diaz Team determined that three Recommendations and 10 Findings could be included The Diaz Team determined that three Recommendations and 10 Findings could be included The Diaz Team determined that three Recommendations and 10 Findings could be included

in the Organizational Structure Category, resulting in four actions.in the Organizational Structure Category, resulting in four actions.in the Organizational Structure Category, resulting in four actions.in the Organizational Structure Category, resulting in four actions.in the Organizational Structure Category, resulting in four actions.in the Organizational Structure Category, resulting in four actions.in the Organizational Structure Category, resulting in four actions.in the Organizational Structure Category, resulting in four actions.in the Organizational Structure Category, resulting in four actions.in the Organizational Structure Category, resulting in four actions.in the Organizational Structure Category, resulting in four actions.in the Organizational Structure Category, resulting in four actions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 445Table 22. Table 22. Table 22. Table 22. The Diaz Team developed one goal for Risk Management.The Diaz Team developed one goal for Risk Management.The Diaz Team developed one goal for Risk Management.The Diaz Team developed one goal for Risk Management.The Diaz Team developed one goal for Risk Management.The Diaz Team developed one goal for Risk Management.The Diaz Team developed one goal for Risk Management.The Diaz Team developed one goal for Risk Management.The Diaz Team developed one goal for Risk Management.The Diaz Team developed one goal for Risk Management.The Diaz Team developed one goal for Risk Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 484848Table 23. Table 23. Table 23. The Diaz Team determined that four Recommendations, two Observations, and 12 Findings The Diaz Team determined that four Recommendations, two Observations, and 12 Findings The Diaz Team determined that four Recommendations, two Observations, and 12 Findings The Diaz Team determined that four Recommendations, two Observations, and 12 Findings The Diaz Team determined that four Recommendations, two Observations, and 12 Findings The Diaz Team determined that four Recommendations, two Observations, and 12 Findings The Diaz Team determined that four Recommendations, two Observations, and 12 Findings The Diaz Team determined that four Recommendations, two Observations, and 12 Findings The Diaz Team determined that four Recommendations, two Observations, and 12 Findings The Diaz Team determined that four Recommendations, two Observations, and 12 Findings The Diaz Team determined that four Recommendations, two Observations, and 12 Findings The Diaz Team determined that four Recommendations, two Observations, and 12 Findings The Diaz Team determined that four Recommendations, two Observations, and 12 Findings The Diaz Team determined that four Recommendations, two Observations, and 12 Findings The Diaz Team determined that four Recommendations, two Observations, and 12 Findings The Diaz Team determined that four Recommendations, two Observations, and 12 Findings

could be included in the Risk Management Category resulting in 11 actions.could be included in the Risk Management Category resulting in 11 actions.could be included in the Risk Management Category resulting in 11 actions.could be included in the Risk Management Category resulting in 11 actions.could be included in the Risk Management Category resulting in 11 actions.could be included in the Risk Management Category resulting in 11 actions.could be included in the Risk Management Category resulting in 11 actions.could be included in the Risk Management Category resulting in 11 actions.could be included in the Risk Management Category resulting in 11 actions.could be included in the Risk Management Category resulting in 11 actions.could be included in the Risk Management Category resulting in 11 actions.could be included in the Risk Management Category resulting in 11 actions.could be included in the Risk Management Category resulting in 11 actions.could be included in the Risk Management Category resulting in 11 actions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4949Table 24. Table 24. Table 24. Diaz Team Goals Diaz Team Goals Diaz Team Goals Diaz Team Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5050

List of FiguresList of FiguresList of FiguresList of FiguresList of Figures

Figure 1. Figure 1. Figure 1. Figure 1. The Diaz Team process required wide acceptance and dissemination of all determinations.The Diaz Team process required wide acceptance and dissemination of all determinations.The Diaz Team process required wide acceptance and dissemination of all determinations.The Diaz Team process required wide acceptance and dissemination of all determinations.The Diaz Team process required wide acceptance and dissemination of all determinations.The Diaz Team process required wide acceptance and dissemination of all determinations.The Diaz Team process required wide acceptance and dissemination of all determinations.The Diaz Team process required wide acceptance and dissemination of all determinations.The Diaz Team process required wide acceptance and dissemination of all determinations.The Diaz Team process required wide acceptance and dissemination of all determinations.The Diaz Team process required wide acceptance and dissemination of all determinations.The Diaz Team process required wide acceptance and dissemination of all determinations.The Diaz Team process required wide acceptance and dissemination of all determinations.The Diaz Team process required wide acceptance and dissemination of all determinations.The Diaz Team process required wide acceptance and dissemination of all determinations.The Diaz Team process required wide acceptance and dissemination of all determinations.The Diaz Team process required wide acceptance and dissemination of all determinations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66Figure 2. Figure 2. Figure 2. Diaz Team determination of broadly applicable R-O-Fs for the Agency.Diaz Team determination of broadly applicable R-O-Fs for the Agency.Diaz Team determination of broadly applicable R-O-Fs for the Agency.Diaz Team determination of broadly applicable R-O-Fs for the Agency.Diaz Team determination of broadly applicable R-O-Fs for the Agency.Diaz Team determination of broadly applicable R-O-Fs for the Agency.Diaz Team determination of broadly applicable R-O-Fs for the Agency.Diaz Team determination of broadly applicable R-O-Fs for the Agency.Diaz Team determination of broadly applicable R-O-Fs for the Agency.Diaz Team determination of broadly applicable R-O-Fs for the Agency.Diaz Team determination of broadly applicable R-O-Fs for the Agency.Diaz Team determination of broadly applicable R-O-Fs for the Agency.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Figure 3. Figure 3. Figure 3. Figure 3. Seven NASA organizations have actions resulting from the Diaz determinations.Seven NASA organizations have actions resulting from the Diaz determinations.Seven NASA organizations have actions resulting from the Diaz determinations.Seven NASA organizations have actions resulting from the Diaz determinations.Seven NASA organizations have actions resulting from the Diaz determinations.Seven NASA organizations have actions resulting from the Diaz determinations.Seven NASA organizations have actions resulting from the Diaz determinations.Seven NASA organizations have actions resulting from the Diaz determinations.Seven NASA organizations have actions resulting from the Diaz determinations.Seven NASA organizations have actions resulting from the Diaz determinations.Seven NASA organizations have actions resulting from the Diaz determinations.Seven NASA organizations have actions resulting from the Diaz determinations.Seven NASA organizations have actions resulting from the Diaz determinations.Seven NASA organizations have actions resulting from the Diaz determinations.Seven NASA organizations have actions resulting from the Diaz determinations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77Figure 4. Figure 4. Figure 4. Overlap currently exists between the Implementation Plans for different organizations. Overlap currently exists between the Implementation Plans for different organizations. Overlap currently exists between the Implementation Plans for different organizations. Overlap currently exists between the Implementation Plans for different organizations. Overlap currently exists between the Implementation Plans for different organizations. Overlap currently exists between the Implementation Plans for different organizations. Overlap currently exists between the Implementation Plans for different organizations. Overlap currently exists between the Implementation Plans for different organizations. Overlap currently exists between the Implementation Plans for different organizations. Overlap currently exists between the Implementation Plans for different organizations. Overlap currently exists between the Implementation Plans for different organizations. Overlap currently exists between the Implementation Plans for different organizations. Overlap currently exists between the Implementation Plans for different organizations. Overlap currently exists between the Implementation Plans for different organizations. Overlap currently exists between the Implementation Plans for different organizations.

NASA Headquarters must coordinate when duplications of efforts might occur. NASA Headquarters must coordinate when duplications of efforts might occur. NASA Headquarters must coordinate when duplications of efforts might occur. NASA Headquarters must coordinate when duplications of efforts might occur. NASA Headquarters must coordinate when duplications of efforts might occur. NASA Headquarters must coordinate when duplications of efforts might occur. NASA Headquarters must coordinate when duplications of efforts might occur. NASA Headquarters must coordinate when duplications of efforts might occur. NASA Headquarters must coordinate when duplications of efforts might occur. NASA Headquarters must coordinate when duplications of efforts might occur. NASA Headquarters must coordinate when duplications of efforts might occur. NASA Headquarters must coordinate when duplications of efforts might occur. NASA Headquarters must coordinate when duplications of efforts might occur. NASA Headquarters must coordinate when duplications of efforts might occur. NASA Headquarters must coordinate when duplications of efforts might occur. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Figure 5. Figure 5. Figure 5. The Diaz Team categorized the CAIB R-O-Fs into seven distinct categories, each of which The Diaz Team categorized the CAIB R-O-Fs into seven distinct categories, each of which The Diaz Team categorized the CAIB R-O-Fs into seven distinct categories, each of which The Diaz Team categorized the CAIB R-O-Fs into seven distinct categories, each of which The Diaz Team categorized the CAIB R-O-Fs into seven distinct categories, each of which The Diaz Team categorized the CAIB R-O-Fs into seven distinct categories, each of which The Diaz Team categorized the CAIB R-O-Fs into seven distinct categories, each of which The Diaz Team categorized the CAIB R-O-Fs into seven distinct categories, each of which The Diaz Team categorized the CAIB R-O-Fs into seven distinct categories, each of which The Diaz Team categorized the CAIB R-O-Fs into seven distinct categories, each of which The Diaz Team categorized the CAIB R-O-Fs into seven distinct categories, each of which The Diaz Team categorized the CAIB R-O-Fs into seven distinct categories, each of which The Diaz Team categorized the CAIB R-O-Fs into seven distinct categories, each of which The Diaz Team categorized the CAIB R-O-Fs into seven distinct categories, each of which The Diaz Team categorized the CAIB R-O-Fs into seven distinct categories, each of which The Diaz Team categorized the CAIB R-O-Fs into seven distinct categories, each of which

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

5

1.11.11.1 INTRODUCTIONINTRODUCTIONINTRODUCTIONINTRODUCTIONINTRODUCTION

The Space Shuttle fl eet has been grounded since the The Space Shuttle fl eet has been grounded since the The Space Shuttle fl eet has been grounded since the The Space Shuttle fl eet has been grounded since the The Space Shuttle fl eet has been grounded since the The Space Shuttle fl eet has been grounded since the The Space Shuttle fl eet has been grounded since the The Space Shuttle fl eet has been grounded since the The Space Shuttle fl eet has been grounded since the The Space Shuttle fl eet has been grounded since the The Space Shuttle fl eet has been grounded since the ColumbiaColumbiaColumbiaColumbiaaccident. As a result, “Return to Flight” has become not just a accident. As a result, “Return to Flight” has become not just a accident. As a result, “Return to Flight” has become not just a accident. As a result, “Return to Flight” has become not just a accident. As a result, “Return to Flight” has become not just a accident. As a result, “Return to Flight” has become not just a accident. As a result, “Return to Flight” has become not just a accident. As a result, “Return to Flight” has become not just a accident. As a result, “Return to Flight” has become not just a accident. As a result, “Return to Flight” has become not just a accident. As a result, “Return to Flight” has become not just a accident. As a result, “Return to Flight” has become not just a phrase but a program, and the goal of virtually everyone asso-phrase but a program, and the goal of virtually everyone asso-phrase but a program, and the goal of virtually everyone asso-phrase but a program, and the goal of virtually everyone asso-phrase but a program, and the goal of virtually everyone asso-phrase but a program, and the goal of virtually everyone asso-phrase but a program, and the goal of virtually everyone asso-phrase but a program, and the goal of virtually everyone asso-phrase but a program, and the goal of virtually everyone asso-phrase but a program, and the goal of virtually everyone asso-phrase but a program, and the goal of virtually everyone asso-phrase but a program, and the goal of virtually everyone asso-phrase but a program, and the goal of virtually everyone asso-ciated with NASA. Even those who are not affi liated with the ciated with NASA. Even those who are not affi liated with the ciated with NASA. Even those who are not affi liated with the ciated with NASA. Even those who are not affi liated with the ciated with NASA. Even those who are not affi liated with the ciated with NASA. Even those who are not affi liated with the ciated with NASA. Even those who are not affi liated with the ciated with NASA. Even those who are not affi liated with the ciated with NASA. Even those who are not affi liated with the ciated with NASA. Even those who are not affi liated with the ciated with NASA. Even those who are not affi liated with the ciated with NASA. Even those who are not affi liated with the Shuttle Program are looking forward to the safe and successful Shuttle Program are looking forward to the safe and successful Shuttle Program are looking forward to the safe and successful Shuttle Program are looking forward to the safe and successful Shuttle Program are looking forward to the safe and successful Shuttle Program are looking forward to the safe and successful Shuttle Program are looking forward to the safe and successful Shuttle Program are looking forward to the safe and successful Shuttle Program are looking forward to the safe and successful Shuttle Program are looking forward to the safe and successful Shuttle Program are looking forward to the safe and successful Shuttle Program are looking forward to the safe and successful Shuttle Program are looking forward to the safe and successful completion of the next Shuttle mission. In this recovery process, completion of the next Shuttle mission. In this recovery process, completion of the next Shuttle mission. In this recovery process, completion of the next Shuttle mission. In this recovery process, completion of the next Shuttle mission. In this recovery process, completion of the next Shuttle mission. In this recovery process, completion of the next Shuttle mission. In this recovery process, completion of the next Shuttle mission. In this recovery process, completion of the next Shuttle mission. In this recovery process, completion of the next Shuttle mission. In this recovery process, completion of the next Shuttle mission. In this recovery process, completion of the next Shuttle mission. In this recovery process, NASA will be guided by the Report of the Columbia Accident NASA will be guided by the Report of the Columbia Accident NASA will be guided by the Report of the Columbia Accident NASA will be guided by the Report of the Columbia Accident NASA will be guided by the Report of the Columbia Accident NASA will be guided by the Report of the Columbia Accident NASA will be guided by the Report of the Columbia Accident NASA will be guided by the Report of the Columbia Accident NASA will be guided by the Report of the Columbia Accident NASA will be guided by the Report of the Columbia Accident NASA will be guided by the Report of the Columbia Accident NASA will be guided by the Report of the Columbia Accident Investigation Board (CAIB).Investigation Board (CAIB).Investigation Board (CAIB).Investigation Board (CAIB).Investigation Board (CAIB).Investigation Board (CAIB).Investigation Board (CAIB).

The CAIB was an investigating body, convened by NASA Ad-The CAIB was an investigating body, convened by NASA Ad-The CAIB was an investigating body, convened by NASA Ad-The CAIB was an investigating body, convened by NASA Ad-The CAIB was an investigating body, convened by NASA Ad-The CAIB was an investigating body, convened by NASA Ad-The CAIB was an investigating body, convened by NASA Ad-The CAIB was an investigating body, convened by NASA Ad-The CAIB was an investigating body, convened by NASA Ad-The CAIB was an investigating body, convened by NASA Ad-The CAIB was an investigating body, convened by NASA Ad-The CAIB was an investigating body, convened by NASA Ad-The CAIB was an investigating body, convened by NASA Ad-ministrator OʼKeefe the day of the ministrator OʼKeefe the day of the ministrator OʼKeefe the day of the ministrator OʼKeefe the day of the ministrator OʼKeefe the day of the ministrator OʼKeefe the day of the ministrator OʼKeefe the day of the ColumbiaColumbia accident, according accident, according accident, according accident, according accident, according to procedures established after the loss of Shuttle to procedures established after the loss of Shuttle to procedures established after the loss of Shuttle to procedures established after the loss of Shuttle to procedures established after the loss of Shuttle to procedures established after the loss of Shuttle to procedures established after the loss of Shuttle to procedures established after the loss of Shuttle to procedures established after the loss of Shuttle to procedures established after the loss of Shuttle ChallengerChallengerChallenger. . . The 13 Board Members and more than 120 staff members ex-The 13 Board Members and more than 120 staff members ex-The 13 Board Members and more than 120 staff members ex-The 13 Board Members and more than 120 staff members ex-The 13 Board Members and more than 120 staff members ex-The 13 Board Members and more than 120 staff members ex-The 13 Board Members and more than 120 staff members ex-The 13 Board Members and more than 120 staff members ex-The 13 Board Members and more than 120 staff members ex-The 13 Board Members and more than 120 staff members ex-The 13 Board Members and more than 120 staff members ex-The 13 Board Members and more than 120 staff members ex-amined more than 30,000 documents, conducted more than amined more than 30,000 documents, conducted more than amined more than 30,000 documents, conducted more than amined more than 30,000 documents, conducted more than amined more than 30,000 documents, conducted more than amined more than 30,000 documents, conducted more than amined more than 30,000 documents, conducted more than amined more than 30,000 documents, conducted more than amined more than 30,000 documents, conducted more than amined more than 30,000 documents, conducted more than amined more than 30,000 documents, conducted more than amined more than 30,000 documents, conducted more than 200 formal interviews, heard testimony from dozens of expert 200 formal interviews, heard testimony from dozens of expert 200 formal interviews, heard testimony from dozens of expert 200 formal interviews, heard testimony from dozens of expert 200 formal interviews, heard testimony from dozens of expert 200 formal interviews, heard testimony from dozens of expert 200 formal interviews, heard testimony from dozens of expert 200 formal interviews, heard testimony from dozens of expert 200 formal interviews, heard testimony from dozens of expert 200 formal interviews, heard testimony from dozens of expert 200 formal interviews, heard testimony from dozens of expert 200 formal interviews, heard testimony from dozens of expert witnesses, and reviewed more than 3,000 public inputs. While witnesses, and reviewed more than 3,000 public inputs. While witnesses, and reviewed more than 3,000 public inputs. While witnesses, and reviewed more than 3,000 public inputs. While witnesses, and reviewed more than 3,000 public inputs. While witnesses, and reviewed more than 3,000 public inputs. While witnesses, and reviewed more than 3,000 public inputs. While witnesses, and reviewed more than 3,000 public inputs. While witnesses, and reviewed more than 3,000 public inputs. While witnesses, and reviewed more than 3,000 public inputs. While witnesses, and reviewed more than 3,000 public inputs. While witnesses, and reviewed more than 3,000 public inputs. While the CAIB maintained strict independence from NASA in its de-the CAIB maintained strict independence from NASA in its de-the CAIB maintained strict independence from NASA in its de-the CAIB maintained strict independence from NASA in its de-the CAIB maintained strict independence from NASA in its de-the CAIB maintained strict independence from NASA in its de-the CAIB maintained strict independence from NASA in its de-the CAIB maintained strict independence from NASA in its de-the CAIB maintained strict independence from NASA in its de-the CAIB maintained strict independence from NASA in its de-the CAIB maintained strict independence from NASA in its de-the CAIB maintained strict independence from NASA in its de-the CAIB maintained strict independence from NASA in its de-liberations and analysis, it did receive technical support from ap-liberations and analysis, it did receive technical support from ap-liberations and analysis, it did receive technical support from ap-liberations and analysis, it did receive technical support from ap-liberations and analysis, it did receive technical support from ap-liberations and analysis, it did receive technical support from ap-liberations and analysis, it did receive technical support from ap-liberations and analysis, it did receive technical support from ap-liberations and analysis, it did receive technical support from ap-liberations and analysis, it did receive technical support from ap-liberations and analysis, it did receive technical support from ap-liberations and analysis, it did receive technical support from ap-proximately 400 NASA engineers. In addition, more than 25,000 proximately 400 NASA engineers. In addition, more than 25,000 proximately 400 NASA engineers. In addition, more than 25,000 proximately 400 NASA engineers. In addition, more than 25,000 proximately 400 NASA engineers. In addition, more than 25,000 proximately 400 NASA engineers. In addition, more than 25,000 proximately 400 NASA engineers. In addition, more than 25,000 proximately 400 NASA engineers. In addition, more than 25,000 proximately 400 NASA engineers. In addition, more than 25,000 proximately 400 NASA engineers. In addition, more than 25,000 proximately 400 NASA engineers. In addition, more than 25,000 proximately 400 NASA engineers. In addition, more than 25,000 proximately 400 NASA engineers. In addition, more than 25,000 searchers helped retrieve the searchers helped retrieve the searchers helped retrieve the searchers helped retrieve the searchers helped retrieve the searchers helped retrieve the ColumbiaColumbia debris. debris. debris.

The CAIB ultimately drew a distinction between the physical The CAIB ultimately drew a distinction between the physical The CAIB ultimately drew a distinction between the physical The CAIB ultimately drew a distinction between the physical The CAIB ultimately drew a distinction between the physical The CAIB ultimately drew a distinction between the physical The CAIB ultimately drew a distinction between the physical The CAIB ultimately drew a distinction between the physical The CAIB ultimately drew a distinction between the physical The CAIB ultimately drew a distinction between the physical The CAIB ultimately drew a distinction between the physical The CAIB ultimately drew a distinction between the physical and organizational causes of the accident, and the Board Report and organizational causes of the accident, and the Board Report and organizational causes of the accident, and the Board Report and organizational causes of the accident, and the Board Report and organizational causes of the accident, and the Board Report and organizational causes of the accident, and the Board Report and organizational causes of the accident, and the Board Report and organizational causes of the accident, and the Board Report and organizational causes of the accident, and the Board Report and organizational causes of the accident, and the Board Report and organizational causes of the accident, and the Board Report and organizational causes of the accident, and the Board Report accordingly included separate causal statements. The physical accordingly included separate causal statements. The physical accordingly included separate causal statements. The physical accordingly included separate causal statements. The physical accordingly included separate causal statements. The physical accordingly included separate causal statements. The physical accordingly included separate causal statements. The physical accordingly included separate causal statements. The physical accordingly included separate causal statements. The physical accordingly included separate causal statements. The physical accordingly included separate causal statements. The physical accordingly included separate causal statements. The physical accordingly included separate causal statements. The physical cause statement documented the sequence of events on Shuttle cause statement documented the sequence of events on Shuttle cause statement documented the sequence of events on Shuttle cause statement documented the sequence of events on Shuttle cause statement documented the sequence of events on Shuttle cause statement documented the sequence of events on Shuttle cause statement documented the sequence of events on Shuttle cause statement documented the sequence of events on Shuttle cause statement documented the sequence of events on Shuttle cause statement documented the sequence of events on Shuttle cause statement documented the sequence of events on Shuttle cause statement documented the sequence of events on Shuttle

Mission STS-107 that led to the breakup of the Orbiter. A variety Mission STS-107 that led to the breakup of the Orbiter. A variety Mission STS-107 that led to the breakup of the Orbiter. A variety Mission STS-107 that led to the breakup of the Orbiter. A variety Mission STS-107 that led to the breakup of the Orbiter. A variety Mission STS-107 that led to the breakup of the Orbiter. A variety Mission STS-107 that led to the breakup of the Orbiter. A variety Mission STS-107 that led to the breakup of the Orbiter. A variety Mission STS-107 that led to the breakup of the Orbiter. A variety Mission STS-107 that led to the breakup of the Orbiter. A variety Mission STS-107 that led to the breakup of the Orbiter. A variety Mission STS-107 that led to the breakup of the Orbiter. A variety Mission STS-107 that led to the breakup of the Orbiter. A variety of separate analyses, each based on its own extensive body of ev-of separate analyses, each based on its own extensive body of ev-of separate analyses, each based on its own extensive body of ev-of separate analyses, each based on its own extensive body of ev-of separate analyses, each based on its own extensive body of ev-of separate analyses, each based on its own extensive body of ev-of separate analyses, each based on its own extensive body of ev-of separate analyses, each based on its own extensive body of ev-of separate analyses, each based on its own extensive body of ev-of separate analyses, each based on its own extensive body of ev-of separate analyses, each based on its own extensive body of ev-of separate analyses, each based on its own extensive body of ev-idence, all pointed to the sequence found in that causal statement idence, all pointed to the sequence found in that causal statement idence, all pointed to the sequence found in that causal statement idence, all pointed to the sequence found in that causal statement idence, all pointed to the sequence found in that causal statement idence, all pointed to the sequence found in that causal statement idence, all pointed to the sequence found in that causal statement idence, all pointed to the sequence found in that causal statement idence, all pointed to the sequence found in that causal statement idence, all pointed to the sequence found in that causal statement idence, all pointed to the sequence found in that causal statement idence, all pointed to the sequence found in that causal statement idence, all pointed to the sequence found in that causal statement of the CAIB Report. The organizational cause statement spells of the CAIB Report. The organizational cause statement spells of the CAIB Report. The organizational cause statement spells of the CAIB Report. The organizational cause statement spells of the CAIB Report. The organizational cause statement spells of the CAIB Report. The organizational cause statement spells of the CAIB Report. The organizational cause statement spells of the CAIB Report. The organizational cause statement spells of the CAIB Report. The organizational cause statement spells of the CAIB Report. The organizational cause statement spells of the CAIB Report. The organizational cause statement spells of the CAIB Report. The organizational cause statement spells out what might be considered the precursors to the physical out what might be considered the precursors to the physical out what might be considered the precursors to the physical out what might be considered the precursors to the physical out what might be considered the precursors to the physical out what might be considered the precursors to the physical out what might be considered the precursors to the physical out what might be considered the precursors to the physical out what might be considered the precursors to the physical out what might be considered the precursors to the physical out what might be considered the precursors to the physical out what might be considered the precursors to the physical out what might be considered the precursors to the physical cause: the conditions that allowed the technical failures to take cause: the conditions that allowed the technical failures to take cause: the conditions that allowed the technical failures to take cause: the conditions that allowed the technical failures to take cause: the conditions that allowed the technical failures to take cause: the conditions that allowed the technical failures to take cause: the conditions that allowed the technical failures to take cause: the conditions that allowed the technical failures to take cause: the conditions that allowed the technical failures to take cause: the conditions that allowed the technical failures to take cause: the conditions that allowed the technical failures to take cause: the conditions that allowed the technical failures to take place and eventually lead to the accident. Table 1 contains the place and eventually lead to the accident. Table 1 contains the place and eventually lead to the accident. Table 1 contains the place and eventually lead to the accident. Table 1 contains the place and eventually lead to the accident. Table 1 contains the place and eventually lead to the accident. Table 1 contains the place and eventually lead to the accident. Table 1 contains the place and eventually lead to the accident. Table 1 contains the place and eventually lead to the accident. Table 1 contains the place and eventually lead to the accident. Table 1 contains the place and eventually lead to the accident. Table 1 contains the place and eventually lead to the accident. Table 1 contains the place and eventually lead to the accident. Table 1 contains the Physical Cause Statement and Organizational Cause Statement.Physical Cause Statement and Organizational Cause Statement.Physical Cause Statement and Organizational Cause Statement.Physical Cause Statement and Organizational Cause Statement.Physical Cause Statement and Organizational Cause Statement.Physical Cause Statement and Organizational Cause Statement.Physical Cause Statement and Organizational Cause Statement.Physical Cause Statement and Organizational Cause Statement.Physical Cause Statement and Organizational Cause Statement.Physical Cause Statement and Organizational Cause Statement.Physical Cause Statement and Organizational Cause Statement.Physical Cause Statement and Organizational Cause Statement.

Of the 29 recommendations in the Report of the CAIB, 15 are Of the 29 recommendations in the Report of the CAIB, 15 are Of the 29 recommendations in the Report of the CAIB, 15 are Of the 29 recommendations in the Report of the CAIB, 15 are Of the 29 recommendations in the Report of the CAIB, 15 are Of the 29 recommendations in the Report of the CAIB, 15 are Of the 29 recommendations in the Report of the CAIB, 15 are Of the 29 recommendations in the Report of the CAIB, 15 are Of the 29 recommendations in the Report of the CAIB, 15 are Of the 29 recommendations in the Report of the CAIB, 15 are Of the 29 recommendations in the Report of the CAIB, 15 are Of the 29 recommendations in the Report of the CAIB, 15 are Of the 29 recommendations in the Report of the CAIB, 15 are designated as “RTF” signifying that they must be completed be-designated as “RTF” signifying that they must be completed be-designated as “RTF” signifying that they must be completed be-designated as “RTF” signifying that they must be completed be-designated as “RTF” signifying that they must be completed be-designated as “RTF” signifying that they must be completed be-designated as “RTF” signifying that they must be completed be-designated as “RTF” signifying that they must be completed be-designated as “RTF” signifying that they must be completed be-designated as “RTF” signifying that they must be completed be-designated as “RTF” signifying that they must be completed be-designated as “RTF” signifying that they must be completed be-fore the Space Shuttle can “Return to Flight.” But the CAIB rec-fore the Space Shuttle can “Return to Flight.” But the CAIB rec-fore the Space Shuttle can “Return to Flight.” But the CAIB rec-fore the Space Shuttle can “Return to Flight.” But the CAIB rec-fore the Space Shuttle can “Return to Flight.” But the CAIB rec-fore the Space Shuttle can “Return to Flight.” But the CAIB rec-fore the Space Shuttle can “Return to Flight.” But the CAIB rec-fore the Space Shuttle can “Return to Flight.” But the CAIB rec-fore the Space Shuttle can “Return to Flight.” But the CAIB rec-fore the Space Shuttle can “Return to Flight.” But the CAIB rec-fore the Space Shuttle can “Return to Flight.” But the CAIB rec-fore the Space Shuttle can “Return to Flight.” But the CAIB rec-fore the Space Shuttle can “Return to Flight.” But the CAIB rec-ognized, and NASA Administrator Sean OʼKeefe has concurred, ognized, and NASA Administrator Sean OʼKeefe has concurred, ognized, and NASA Administrator Sean OʼKeefe has concurred, ognized, and NASA Administrator Sean OʼKeefe has concurred, ognized, and NASA Administrator Sean OʼKeefe has concurred, ognized, and NASA Administrator Sean OʼKeefe has concurred, ognized, and NASA Administrator Sean OʼKeefe has concurred, ognized, and NASA Administrator Sean OʼKeefe has concurred, ognized, and NASA Administrator Sean OʼKeefe has concurred, ognized, and NASA Administrator Sean OʼKeefe has concurred, ognized, and NASA Administrator Sean OʼKeefe has concurred, ognized, and NASA Administrator Sean OʼKeefe has concurred, that the problems at NASA extend beyond what is addressed in that the problems at NASA extend beyond what is addressed in that the problems at NASA extend beyond what is addressed in that the problems at NASA extend beyond what is addressed in that the problems at NASA extend beyond what is addressed in that the problems at NASA extend beyond what is addressed in that the problems at NASA extend beyond what is addressed in that the problems at NASA extend beyond what is addressed in that the problems at NASA extend beyond what is addressed in that the problems at NASA extend beyond what is addressed in that the problems at NASA extend beyond what is addressed in that the problems at NASA extend beyond what is addressed in that the problems at NASA extend beyond what is addressed in those 15 recommendations. That is why the CAIB Report con-those 15 recommendations. That is why the CAIB Report con-those 15 recommendations. That is why the CAIB Report con-those 15 recommendations. That is why the CAIB Report con-those 15 recommendations. That is why the CAIB Report con-those 15 recommendations. That is why the CAIB Report con-those 15 recommendations. That is why the CAIB Report con-those 15 recommendations. That is why the CAIB Report con-those 15 recommendations. That is why the CAIB Report con-those 15 recommendations. That is why the CAIB Report con-those 15 recommendations. That is why the CAIB Report con-those 15 recommendations. That is why the CAIB Report con-tains 14 more recommendations, as well as 27 observations and tains 14 more recommendations, as well as 27 observations and tains 14 more recommendations, as well as 27 observations and tains 14 more recommendations, as well as 27 observations and tains 14 more recommendations, as well as 27 observations and tains 14 more recommendations, as well as 27 observations and tains 14 more recommendations, as well as 27 observations and tains 14 more recommendations, as well as 27 observations and tains 14 more recommendations, as well as 27 observations and tains 14 more recommendations, as well as 27 observations and tains 14 more recommendations, as well as 27 observations and tains 14 more recommendations, as well as 27 observations and 137 fi ndings. Most of these are specifi c to the long-term opera-137 fi ndings. Most of these are specifi c to the long-term opera-137 fi ndings. Most of these are specifi c to the long-term opera-137 fi ndings. Most of these are specifi c to the long-term opera-137 fi ndings. Most of these are specifi c to the long-term opera-137 fi ndings. Most of these are specifi c to the long-term opera-137 fi ndings. Most of these are specifi c to the long-term opera-137 fi ndings. Most of these are specifi c to the long-term opera-137 fi ndings. Most of these are specifi c to the long-term opera-137 fi ndings. Most of these are specifi c to the long-term opera-137 fi ndings. Most of these are specifi c to the long-term opera-tion of the Human Space Flight Program, but the Administrator tion of the Human Space Flight Program, but the Administrator tion of the Human Space Flight Program, but the Administrator tion of the Human Space Flight Program, but the Administrator tion of the Human Space Flight Program, but the Administrator tion of the Human Space Flight Program, but the Administrator tion of the Human Space Flight Program, but the Administrator tion of the Human Space Flight Program, but the Administrator tion of the Human Space Flight Program, but the Administrator tion of the Human Space Flight Program, but the Administrator tion of the Human Space Flight Program, but the Administrator tion of the Human Space Flight Program, but the Administrator recognized that a substantial number might be applied across the recognized that a substantial number might be applied across the recognized that a substantial number might be applied across the recognized that a substantial number might be applied across the recognized that a substantial number might be applied across the recognized that a substantial number might be applied across the recognized that a substantial number might be applied across the recognized that a substantial number might be applied across the recognized that a substantial number might be applied across the recognized that a substantial number might be applied across the recognized that a substantial number might be applied across the recognized that a substantial number might be applied across the recognized that a substantial number might be applied across the Agency. Taking these necessary prescribed steps will ensure, Agency. Taking these necessary prescribed steps will ensure, Agency. Taking these necessary prescribed steps will ensure, Agency. Taking these necessary prescribed steps will ensure, Agency. Taking these necessary prescribed steps will ensure, Agency. Taking these necessary prescribed steps will ensure, Agency. Taking these necessary prescribed steps will ensure, Agency. Taking these necessary prescribed steps will ensure, Agency. Taking these necessary prescribed steps will ensure, Agency. Taking these necessary prescribed steps will ensure, Agency. Taking these necessary prescribed steps will ensure, Agency. Taking these necessary prescribed steps will ensure, in the opinion of the Diaz Team, that not only will the Shuttle in the opinion of the Diaz Team, that not only will the Shuttle in the opinion of the Diaz Team, that not only will the Shuttle in the opinion of the Diaz Team, that not only will the Shuttle in the opinion of the Diaz Team, that not only will the Shuttle in the opinion of the Diaz Team, that not only will the Shuttle in the opinion of the Diaz Team, that not only will the Shuttle in the opinion of the Diaz Team, that not only will the Shuttle in the opinion of the Diaz Team, that not only will the Shuttle in the opinion of the Diaz Team, that not only will the Shuttle in the opinion of the Diaz Team, that not only will the Shuttle in the opinion of the Diaz Team, that not only will the Shuttle in the opinion of the Diaz Team, that not only will the Shuttle “Return to Flight,” but all of NASA will renew its commitment “Return to Flight,” but all of NASA will renew its commitment “Return to Flight,” but all of NASA will renew its commitment “Return to Flight,” but all of NASA will renew its commitment “Return to Flight,” but all of NASA will renew its commitment “Return to Flight,” but all of NASA will renew its commitment “Return to Flight,” but all of NASA will renew its commitment “Return to Flight,” but all of NASA will renew its commitment “Return to Flight,” but all of NASA will renew its commitment “Return to Flight,” but all of NASA will renew its commitment “Return to Flight,” but all of NASA will renew its commitment “Return to Flight,” but all of NASA will renew its commitment to excellence.to excellence.to excellence.to excellence.

Which are the recommendations, observations, and fi ndings (R-Which are the recommendations, observations, and fi ndings (R-Which are the recommendations, observations, and fi ndings (R-Which are the recommendations, observations, and fi ndings (R-Which are the recommendations, observations, and fi ndings (R-Which are the recommendations, observations, and fi ndings (R-Which are the recommendations, observations, and fi ndings (R-Which are the recommendations, observations, and fi ndings (R-Which are the recommendations, observations, and fi ndings (R-Which are the recommendations, observations, and fi ndings (R-Which are the recommendations, observations, and fi ndings (R-Which are the recommendations, observations, and fi ndings (R-O-Fs) that have this broad applicability Agency-wide? That is O-Fs) that have this broad applicability Agency-wide? That is O-Fs) that have this broad applicability Agency-wide? That is O-Fs) that have this broad applicability Agency-wide? That is O-Fs) that have this broad applicability Agency-wide? That is O-Fs) that have this broad applicability Agency-wide? That is O-Fs) that have this broad applicability Agency-wide? That is O-Fs) that have this broad applicability Agency-wide? That is O-Fs) that have this broad applicability Agency-wide? That is O-Fs) that have this broad applicability Agency-wide? That is O-Fs) that have this broad applicability Agency-wide? That is O-Fs) that have this broad applicability Agency-wide? That is O-Fs) that have this broad applicability Agency-wide? That is the question that NASA̓ s Administrator put to a team comprised the question that NASA̓ s Administrator put to a team comprised the question that NASA̓ s Administrator put to a team comprised the question that NASA̓ s Administrator put to a team comprised the question that NASA̓ s Administrator put to a team comprised the question that NASA̓ s Administrator put to a team comprised the question that NASA̓ s Administrator put to a team comprised the question that NASA̓ s Administrator put to a team comprised the question that NASA̓ s Administrator put to a team comprised the question that NASA̓ s Administrator put to a team comprised the question that NASA̓ s Administrator put to a team comprised the question that NASA̓ s Administrator put to a team comprised

1.0 EXECUTIVE SUMMARY

The Diaz Team’s Charter:• Identify those R-O-Fs from the CAIB Report that might apply across the Agency.• Identify a set of actions and suggested leadership for those actions.• Include the One NASA* Team in all activities.• Summarize results in a Report to the NASA Deputy Administrator.

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

Physical Cause and Organizational Cause

CAIB Report Chapter 3, p49:CAIB Report Chapter 3, p49:CAIB Report Chapter 3, p49:CAIB Report Chapter 3, p49:CAIB Report Chapter 3, p49:CAIB Report Chapter 3, p49:The physical cause of the loss of The physical cause of the loss of The physical cause of the loss of The physical cause of the loss of The physical cause of the loss of The physical cause of the loss of Columbia Columbia and its crew was a breach in the Thermal Protection System on the leading edge of the and its crew was a breach in the Thermal Protection System on the leading edge of the and its crew was a breach in the Thermal Protection System on the leading edge of the and its crew was a breach in the Thermal Protection System on the leading edge of the and its crew was a breach in the Thermal Protection System on the leading edge of the and its crew was a breach in the Thermal Protection System on the leading edge of the and its crew was a breach in the Thermal Protection System on the leading edge of the and its crew was a breach in the Thermal Protection System on the leading edge of the and its crew was a breach in the Thermal Protection System on the leading edge of the and its crew was a breach in the Thermal Protection System on the leading edge of the and its crew was a breach in the Thermal Protection System on the leading edge of the and its crew was a breach in the Thermal Protection System on the leading edge of the and its crew was a breach in the Thermal Protection System on the leading edge of the and its crew was a breach in the Thermal Protection System on the leading edge of the left wing. The breach was initiated by a piece of insulating foam that separated from the left bipod ramp of the External Tank and left wing. The breach was initiated by a piece of insulating foam that separated from the left bipod ramp of the External Tank and left wing. The breach was initiated by a piece of insulating foam that separated from the left bipod ramp of the External Tank and left wing. The breach was initiated by a piece of insulating foam that separated from the left bipod ramp of the External Tank and left wing. The breach was initiated by a piece of insulating foam that separated from the left bipod ramp of the External Tank and left wing. The breach was initiated by a piece of insulating foam that separated from the left bipod ramp of the External Tank and left wing. The breach was initiated by a piece of insulating foam that separated from the left bipod ramp of the External Tank and left wing. The breach was initiated by a piece of insulating foam that separated from the left bipod ramp of the External Tank and left wing. The breach was initiated by a piece of insulating foam that separated from the left bipod ramp of the External Tank and left wing. The breach was initiated by a piece of insulating foam that separated from the left bipod ramp of the External Tank and left wing. The breach was initiated by a piece of insulating foam that separated from the left bipod ramp of the External Tank and left wing. The breach was initiated by a piece of insulating foam that separated from the left bipod ramp of the External Tank and left wing. The breach was initiated by a piece of insulating foam that separated from the left bipod ramp of the External Tank and left wing. The breach was initiated by a piece of insulating foam that separated from the left bipod ramp of the External Tank and left wing. The breach was initiated by a piece of insulating foam that separated from the left bipod ramp of the External Tank and left wing. The breach was initiated by a piece of insulating foam that separated from the left bipod ramp of the External Tank and left wing. The breach was initiated by a piece of insulating foam that separated from the left bipod ramp of the External Tank and left wing. The breach was initiated by a piece of insulating foam that separated from the left bipod ramp of the External Tank and left wing. The breach was initiated by a piece of insulating foam that separated from the left bipod ramp of the External Tank and left wing. The breach was initiated by a piece of insulating foam that separated from the left bipod ramp of the External Tank and left wing. The breach was initiated by a piece of insulating foam that separated from the left bipod ramp of the External Tank and left wing. The breach was initiated by a piece of insulating foam that separated from the left bipod ramp of the External Tank and struck the wing in the vicinity of the lower half of Reinforced Carbon-Carbon panel 8 at 81.9 seconds after launch. During re-entry, struck the wing in the vicinity of the lower half of Reinforced Carbon-Carbon panel 8 at 81.9 seconds after launch. During re-entry, struck the wing in the vicinity of the lower half of Reinforced Carbon-Carbon panel 8 at 81.9 seconds after launch. During re-entry, struck the wing in the vicinity of the lower half of Reinforced Carbon-Carbon panel 8 at 81.9 seconds after launch. During re-entry, struck the wing in the vicinity of the lower half of Reinforced Carbon-Carbon panel 8 at 81.9 seconds after launch. During re-entry, struck the wing in the vicinity of the lower half of Reinforced Carbon-Carbon panel 8 at 81.9 seconds after launch. During re-entry, struck the wing in the vicinity of the lower half of Reinforced Carbon-Carbon panel 8 at 81.9 seconds after launch. During re-entry, struck the wing in the vicinity of the lower half of Reinforced Carbon-Carbon panel 8 at 81.9 seconds after launch. During re-entry, struck the wing in the vicinity of the lower half of Reinforced Carbon-Carbon panel 8 at 81.9 seconds after launch. During re-entry, struck the wing in the vicinity of the lower half of Reinforced Carbon-Carbon panel 8 at 81.9 seconds after launch. During re-entry, struck the wing in the vicinity of the lower half of Reinforced Carbon-Carbon panel 8 at 81.9 seconds after launch. During re-entry, struck the wing in the vicinity of the lower half of Reinforced Carbon-Carbon panel 8 at 81.9 seconds after launch. During re-entry, struck the wing in the vicinity of the lower half of Reinforced Carbon-Carbon panel 8 at 81.9 seconds after launch. During re-entry, struck the wing in the vicinity of the lower half of Reinforced Carbon-Carbon panel 8 at 81.9 seconds after launch. During re-entry, struck the wing in the vicinity of the lower half of Reinforced Carbon-Carbon panel 8 at 81.9 seconds after launch. During re-entry, struck the wing in the vicinity of the lower half of Reinforced Carbon-Carbon panel 8 at 81.9 seconds after launch. During re-entry, struck the wing in the vicinity of the lower half of Reinforced Carbon-Carbon panel 8 at 81.9 seconds after launch. During re-entry, struck the wing in the vicinity of the lower half of Reinforced Carbon-Carbon panel 8 at 81.9 seconds after launch. During re-entry, struck the wing in the vicinity of the lower half of Reinforced Carbon-Carbon panel 8 at 81.9 seconds after launch. During re-entry, struck the wing in the vicinity of the lower half of Reinforced Carbon-Carbon panel 8 at 81.9 seconds after launch. During re-entry, struck the wing in the vicinity of the lower half of Reinforced Carbon-Carbon panel 8 at 81.9 seconds after launch. During re-entry, this breach in the Thermal Protection System allowed superheated air to penetrate the leading-edge insulation and progressively this breach in the Thermal Protection System allowed superheated air to penetrate the leading-edge insulation and progressively this breach in the Thermal Protection System allowed superheated air to penetrate the leading-edge insulation and progressively this breach in the Thermal Protection System allowed superheated air to penetrate the leading-edge insulation and progressively this breach in the Thermal Protection System allowed superheated air to penetrate the leading-edge insulation and progressively this breach in the Thermal Protection System allowed superheated air to penetrate the leading-edge insulation and progressively this breach in the Thermal Protection System allowed superheated air to penetrate the leading-edge insulation and progressively this breach in the Thermal Protection System allowed superheated air to penetrate the leading-edge insulation and progressively this breach in the Thermal Protection System allowed superheated air to penetrate the leading-edge insulation and progressively this breach in the Thermal Protection System allowed superheated air to penetrate the leading-edge insulation and progressively this breach in the Thermal Protection System allowed superheated air to penetrate the leading-edge insulation and progressively this breach in the Thermal Protection System allowed superheated air to penetrate the leading-edge insulation and progressively this breach in the Thermal Protection System allowed superheated air to penetrate the leading-edge insulation and progressively this breach in the Thermal Protection System allowed superheated air to penetrate the leading-edge insulation and progressively this breach in the Thermal Protection System allowed superheated air to penetrate the leading-edge insulation and progressively this breach in the Thermal Protection System allowed superheated air to penetrate the leading-edge insulation and progressively this breach in the Thermal Protection System allowed superheated air to penetrate the leading-edge insulation and progressively this breach in the Thermal Protection System allowed superheated air to penetrate the leading-edge insulation and progressively this breach in the Thermal Protection System allowed superheated air to penetrate the leading-edge insulation and progressively this breach in the Thermal Protection System allowed superheated air to penetrate the leading-edge insulation and progressively this breach in the Thermal Protection System allowed superheated air to penetrate the leading-edge insulation and progressively this breach in the Thermal Protection System allowed superheated air to penetrate the leading-edge insulation and progressively melt the aluminum structure of the left wing, resulting in a weakening of the structure until increasing aerodynamic forces caused melt the aluminum structure of the left wing, resulting in a weakening of the structure until increasing aerodynamic forces caused melt the aluminum structure of the left wing, resulting in a weakening of the structure until increasing aerodynamic forces caused melt the aluminum structure of the left wing, resulting in a weakening of the structure until increasing aerodynamic forces caused melt the aluminum structure of the left wing, resulting in a weakening of the structure until increasing aerodynamic forces caused melt the aluminum structure of the left wing, resulting in a weakening of the structure until increasing aerodynamic forces caused melt the aluminum structure of the left wing, resulting in a weakening of the structure until increasing aerodynamic forces caused melt the aluminum structure of the left wing, resulting in a weakening of the structure until increasing aerodynamic forces caused melt the aluminum structure of the left wing, resulting in a weakening of the structure until increasing aerodynamic forces caused melt the aluminum structure of the left wing, resulting in a weakening of the structure until increasing aerodynamic forces caused melt the aluminum structure of the left wing, resulting in a weakening of the structure until increasing aerodynamic forces caused melt the aluminum structure of the left wing, resulting in a weakening of the structure until increasing aerodynamic forces caused melt the aluminum structure of the left wing, resulting in a weakening of the structure until increasing aerodynamic forces caused melt the aluminum structure of the left wing, resulting in a weakening of the structure until increasing aerodynamic forces caused melt the aluminum structure of the left wing, resulting in a weakening of the structure until increasing aerodynamic forces caused melt the aluminum structure of the left wing, resulting in a weakening of the structure until increasing aerodynamic forces caused melt the aluminum structure of the left wing, resulting in a weakening of the structure until increasing aerodynamic forces caused melt the aluminum structure of the left wing, resulting in a weakening of the structure until increasing aerodynamic forces caused melt the aluminum structure of the left wing, resulting in a weakening of the structure until increasing aerodynamic forces caused melt the aluminum structure of the left wing, resulting in a weakening of the structure until increasing aerodynamic forces caused melt the aluminum structure of the left wing, resulting in a weakening of the structure until increasing aerodynamic forces caused loss of control, failure of the wing, and breakup of the Orbiter.loss of control, failure of the wing, and breakup of the Orbiter.loss of control, failure of the wing, and breakup of the Orbiter.loss of control, failure of the wing, and breakup of the Orbiter.loss of control, failure of the wing, and breakup of the Orbiter.loss of control, failure of the wing, and breakup of the Orbiter.loss of control, failure of the wing, and breakup of the Orbiter.loss of control, failure of the wing, and breakup of the Orbiter.loss of control, failure of the wing, and breakup of the Orbiter.loss of control, failure of the wing, and breakup of the Orbiter.

CAIB Report Chapter 7, p177:CAIB Report Chapter 7, p177:CAIB Report Chapter 7, p177:CAIB Report Chapter 7, p177:CAIB Report Chapter 7, p177:CAIB Report Chapter 7, p177:The organizational causes of this accident are rooted in the Space Shuttle Program’s history and culture, including the original The organizational causes of this accident are rooted in the Space Shuttle Program’s history and culture, including the original The organizational causes of this accident are rooted in the Space Shuttle Program’s history and culture, including the original The organizational causes of this accident are rooted in the Space Shuttle Program’s history and culture, including the original The organizational causes of this accident are rooted in the Space Shuttle Program’s history and culture, including the original The organizational causes of this accident are rooted in the Space Shuttle Program’s history and culture, including the original The organizational causes of this accident are rooted in the Space Shuttle Program’s history and culture, including the original The organizational causes of this accident are rooted in the Space Shuttle Program’s history and culture, including the original The organizational causes of this accident are rooted in the Space Shuttle Program’s history and culture, including the original The organizational causes of this accident are rooted in the Space Shuttle Program’s history and culture, including the original The organizational causes of this accident are rooted in the Space Shuttle Program’s history and culture, including the original The organizational causes of this accident are rooted in the Space Shuttle Program’s history and culture, including the original The organizational causes of this accident are rooted in the Space Shuttle Program’s history and culture, including the original The organizational causes of this accident are rooted in the Space Shuttle Program’s history and culture, including the original The organizational causes of this accident are rooted in the Space Shuttle Program’s history and culture, including the original The organizational causes of this accident are rooted in the Space Shuttle Program’s history and culture, including the original The organizational causes of this accident are rooted in the Space Shuttle Program’s history and culture, including the original The organizational causes of this accident are rooted in the Space Shuttle Program’s history and culture, including the original The organizational causes of this accident are rooted in the Space Shuttle Program’s history and culture, including the original The organizational causes of this accident are rooted in the Space Shuttle Program’s history and culture, including the original The organizational causes of this accident are rooted in the Space Shuttle Program’s history and culture, including the original The organizational causes of this accident are rooted in the Space Shuttle Program’s history and culture, including the original compromises that were required to gain approval for the Shuttle Program, subsequent years of resource constraints, fl uctuating compromises that were required to gain approval for the Shuttle Program, subsequent years of resource constraints, fl uctuating compromises that were required to gain approval for the Shuttle Program, subsequent years of resource constraints, fl uctuating compromises that were required to gain approval for the Shuttle Program, subsequent years of resource constraints, fl uctuating compromises that were required to gain approval for the Shuttle Program, subsequent years of resource constraints, fl uctuating compromises that were required to gain approval for the Shuttle Program, subsequent years of resource constraints, fl uctuating compromises that were required to gain approval for the Shuttle Program, subsequent years of resource constraints, fl uctuating compromises that were required to gain approval for the Shuttle Program, subsequent years of resource constraints, fl uctuating compromises that were required to gain approval for the Shuttle Program, subsequent years of resource constraints, fl uctuating compromises that were required to gain approval for the Shuttle Program, subsequent years of resource constraints, fl uctuating compromises that were required to gain approval for the Shuttle Program, subsequent years of resource constraints, fl uctuating compromises that were required to gain approval for the Shuttle Program, subsequent years of resource constraints, fl uctuating compromises that were required to gain approval for the Shuttle Program, subsequent years of resource constraints, fl uctuating compromises that were required to gain approval for the Shuttle Program, subsequent years of resource constraints, fl uctuating compromises that were required to gain approval for the Shuttle Program, subsequent years of resource constraints, fl uctuating compromises that were required to gain approval for the Shuttle Program, subsequent years of resource constraints, fl uctuating compromises that were required to gain approval for the Shuttle Program, subsequent years of resource constraints, fl uctuating compromises that were required to gain approval for the Shuttle Program, subsequent years of resource constraints, fl uctuating compromises that were required to gain approval for the Shuttle Program, subsequent years of resource constraints, fl uctuating compromises that were required to gain approval for the Shuttle Program, subsequent years of resource constraints, fl uctuating compromises that were required to gain approval for the Shuttle Program, subsequent years of resource constraints, fl uctuating priorities, schedule pressures, mischaracterizations of the Shuttle as operational rather than developmental, and lack of an agreed priorities, schedule pressures, mischaracterizations of the Shuttle as operational rather than developmental, and lack of an agreed priorities, schedule pressures, mischaracterizations of the Shuttle as operational rather than developmental, and lack of an agreed priorities, schedule pressures, mischaracterizations of the Shuttle as operational rather than developmental, and lack of an agreed priorities, schedule pressures, mischaracterizations of the Shuttle as operational rather than developmental, and lack of an agreed priorities, schedule pressures, mischaracterizations of the Shuttle as operational rather than developmental, and lack of an agreed priorities, schedule pressures, mischaracterizations of the Shuttle as operational rather than developmental, and lack of an agreed priorities, schedule pressures, mischaracterizations of the Shuttle as operational rather than developmental, and lack of an agreed priorities, schedule pressures, mischaracterizations of the Shuttle as operational rather than developmental, and lack of an agreed priorities, schedule pressures, mischaracterizations of the Shuttle as operational rather than developmental, and lack of an agreed priorities, schedule pressures, mischaracterizations of the Shuttle as operational rather than developmental, and lack of an agreed priorities, schedule pressures, mischaracterizations of the Shuttle as operational rather than developmental, and lack of an agreed priorities, schedule pressures, mischaracterizations of the Shuttle as operational rather than developmental, and lack of an agreed priorities, schedule pressures, mischaracterizations of the Shuttle as operational rather than developmental, and lack of an agreed priorities, schedule pressures, mischaracterizations of the Shuttle as operational rather than developmental, and lack of an agreed priorities, schedule pressures, mischaracterizations of the Shuttle as operational rather than developmental, and lack of an agreed priorities, schedule pressures, mischaracterizations of the Shuttle as operational rather than developmental, and lack of an agreed priorities, schedule pressures, mischaracterizations of the Shuttle as operational rather than developmental, and lack of an agreed priorities, schedule pressures, mischaracterizations of the Shuttle as operational rather than developmental, and lack of an agreed priorities, schedule pressures, mischaracterizations of the Shuttle as operational rather than developmental, and lack of an agreed priorities, schedule pressures, mischaracterizations of the Shuttle as operational rather than developmental, and lack of an agreed priorities, schedule pressures, mischaracterizations of the Shuttle as operational rather than developmental, and lack of an agreed national vision. Cultural traits and organizational practices detrimental to safety were allowed to develop, including: reliance on national vision. Cultural traits and organizational practices detrimental to safety were allowed to develop, including: reliance on national vision. Cultural traits and organizational practices detrimental to safety were allowed to develop, including: reliance on national vision. Cultural traits and organizational practices detrimental to safety were allowed to develop, including: reliance on national vision. Cultural traits and organizational practices detrimental to safety were allowed to develop, including: reliance on national vision. Cultural traits and organizational practices detrimental to safety were allowed to develop, including: reliance on national vision. Cultural traits and organizational practices detrimental to safety were allowed to develop, including: reliance on national vision. Cultural traits and organizational practices detrimental to safety were allowed to develop, including: reliance on national vision. Cultural traits and organizational practices detrimental to safety were allowed to develop, including: reliance on national vision. Cultural traits and organizational practices detrimental to safety were allowed to develop, including: reliance on national vision. Cultural traits and organizational practices detrimental to safety were allowed to develop, including: reliance on national vision. Cultural traits and organizational practices detrimental to safety were allowed to develop, including: reliance on national vision. Cultural traits and organizational practices detrimental to safety were allowed to develop, including: reliance on national vision. Cultural traits and organizational practices detrimental to safety were allowed to develop, including: reliance on national vision. Cultural traits and organizational practices detrimental to safety were allowed to develop, including: reliance on national vision. Cultural traits and organizational practices detrimental to safety were allowed to develop, including: reliance on national vision. Cultural traits and organizational practices detrimental to safety were allowed to develop, including: reliance on national vision. Cultural traits and organizational practices detrimental to safety were allowed to develop, including: reliance on national vision. Cultural traits and organizational practices detrimental to safety were allowed to develop, including: reliance on national vision. Cultural traits and organizational practices detrimental to safety were allowed to develop, including: reliance on national vision. Cultural traits and organizational practices detrimental to safety were allowed to develop, including: reliance on past success as a substitute for sound engineering practices (such as testing to understand why systems were not performing past success as a substitute for sound engineering practices (such as testing to understand why systems were not performing past success as a substitute for sound engineering practices (such as testing to understand why systems were not performing past success as a substitute for sound engineering practices (such as testing to understand why systems were not performing past success as a substitute for sound engineering practices (such as testing to understand why systems were not performing past success as a substitute for sound engineering practices (such as testing to understand why systems were not performing past success as a substitute for sound engineering practices (such as testing to understand why systems were not performing past success as a substitute for sound engineering practices (such as testing to understand why systems were not performing past success as a substitute for sound engineering practices (such as testing to understand why systems were not performing past success as a substitute for sound engineering practices (such as testing to understand why systems were not performing past success as a substitute for sound engineering practices (such as testing to understand why systems were not performing past success as a substitute for sound engineering practices (such as testing to understand why systems were not performing past success as a substitute for sound engineering practices (such as testing to understand why systems were not performing past success as a substitute for sound engineering practices (such as testing to understand why systems were not performing past success as a substitute for sound engineering practices (such as testing to understand why systems were not performing past success as a substitute for sound engineering practices (such as testing to understand why systems were not performing past success as a substitute for sound engineering practices (such as testing to understand why systems were not performing past success as a substitute for sound engineering practices (such as testing to understand why systems were not performing past success as a substitute for sound engineering practices (such as testing to understand why systems were not performing past success as a substitute for sound engineering practices (such as testing to understand why systems were not performing past success as a substitute for sound engineering practices (such as testing to understand why systems were not performing past success as a substitute for sound engineering practices (such as testing to understand why systems were not performing in accordance with requirements/specifi cations); organizational barriers that prevented effective communication of critical safety in accordance with requirements/specifi cations); organizational barriers that prevented effective communication of critical safety in accordance with requirements/specifi cations); organizational barriers that prevented effective communication of critical safety in accordance with requirements/specifi cations); organizational barriers that prevented effective communication of critical safety in accordance with requirements/specifi cations); organizational barriers that prevented effective communication of critical safety in accordance with requirements/specifi cations); organizational barriers that prevented effective communication of critical safety in accordance with requirements/specifi cations); organizational barriers that prevented effective communication of critical safety in accordance with requirements/specifi cations); organizational barriers that prevented effective communication of critical safety in accordance with requirements/specifi cations); organizational barriers that prevented effective communication of critical safety in accordance with requirements/specifi cations); organizational barriers that prevented effective communication of critical safety in accordance with requirements/specifi cations); organizational barriers that prevented effective communication of critical safety in accordance with requirements/specifi cations); organizational barriers that prevented effective communication of critical safety in accordance with requirements/specifi cations); organizational barriers that prevented effective communication of critical safety in accordance with requirements/specifi cations); organizational barriers that prevented effective communication of critical safety in accordance with requirements/specifi cations); organizational barriers that prevented effective communication of critical safety in accordance with requirements/specifi cations); organizational barriers that prevented effective communication of critical safety in accordance with requirements/specifi cations); organizational barriers that prevented effective communication of critical safety in accordance with requirements/specifi cations); organizational barriers that prevented effective communication of critical safety in accordance with requirements/specifi cations); organizational barriers that prevented effective communication of critical safety in accordance with requirements/specifi cations); organizational barriers that prevented effective communication of critical safety in accordance with requirements/specifi cations); organizational barriers that prevented effective communication of critical safety information and stifl ed professional differences of opinion; lack of integrated management across program elements; and the information and stifl ed professional differences of opinion; lack of integrated management across program elements; and the information and stifl ed professional differences of opinion; lack of integrated management across program elements; and the information and stifl ed professional differences of opinion; lack of integrated management across program elements; and the information and stifl ed professional differences of opinion; lack of integrated management across program elements; and the information and stifl ed professional differences of opinion; lack of integrated management across program elements; and the information and stifl ed professional differences of opinion; lack of integrated management across program elements; and the information and stifl ed professional differences of opinion; lack of integrated management across program elements; and the information and stifl ed professional differences of opinion; lack of integrated management across program elements; and the information and stifl ed professional differences of opinion; lack of integrated management across program elements; and the information and stifl ed professional differences of opinion; lack of integrated management across program elements; and the information and stifl ed professional differences of opinion; lack of integrated management across program elements; and the information and stifl ed professional differences of opinion; lack of integrated management across program elements; and the information and stifl ed professional differences of opinion; lack of integrated management across program elements; and the information and stifl ed professional differences of opinion; lack of integrated management across program elements; and the information and stifl ed professional differences of opinion; lack of integrated management across program elements; and the information and stifl ed professional differences of opinion; lack of integrated management across program elements; and the information and stifl ed professional differences of opinion; lack of integrated management across program elements; and the information and stifl ed professional differences of opinion; lack of integrated management across program elements; and the information and stifl ed professional differences of opinion; lack of integrated management across program elements; and the evolution of an informal chain of command and decision-making processes that operated outside the organization’s rules.evolution of an informal chain of command and decision-making processes that operated outside the organization’s rules.evolution of an informal chain of command and decision-making processes that operated outside the organization’s rules.evolution of an informal chain of command and decision-making processes that operated outside the organization’s rules.evolution of an informal chain of command and decision-making processes that operated outside the organization’s rules.evolution of an informal chain of command and decision-making processes that operated outside the organization’s rules.evolution of an informal chain of command and decision-making processes that operated outside the organization’s rules.evolution of an informal chain of command and decision-making processes that operated outside the organization’s rules.evolution of an informal chain of command and decision-making processes that operated outside the organization’s rules.evolution of an informal chain of command and decision-making processes that operated outside the organization’s rules.evolution of an informal chain of command and decision-making processes that operated outside the organization’s rules.evolution of an informal chain of command and decision-making processes that operated outside the organization’s rules.evolution of an informal chain of command and decision-making processes that operated outside the organization’s rules.evolution of an informal chain of command and decision-making processes that operated outside the organization’s rules.evolution of an informal chain of command and decision-making processes that operated outside the organization’s rules.evolution of an informal chain of command and decision-making processes that operated outside the organization’s rules.evolution of an informal chain of command and decision-making processes that operated outside the organization’s rules.evolution of an informal chain of command and decision-making processes that operated outside the organization’s rules.evolution of an informal chain of command and decision-making processes that operated outside the organization’s rules.evolution of an informal chain of command and decision-making processes that operated outside the organization’s rules.evolution of an informal chain of command and decision-making processes that operated outside the organization’s rules.

* The One NASA effort was initiated prior to the The One NASA effort was initiated prior to the The One NASA effort was initiated prior to the The One NASA effort was initiated prior to the The One NASA effort was initiated prior to the The One NASA effort was initiated prior to the The One NASA effort was initiated prior to the Columbia Columbia Columbia accident by a group of middle managers from across the Agency. The vision of One NASA is accident by a group of middle managers from across the Agency. The vision of One NASA is accident by a group of middle managers from across the Agency. The vision of One NASA is accident by a group of middle managers from across the Agency. The vision of One NASA is accident by a group of middle managers from across the Agency. The vision of One NASA is accident by a group of middle managers from across the Agency. The vision of One NASA is accident by a group of middle managers from across the Agency. The vision of One NASA is accident by a group of middle managers from across the Agency. The vision of One NASA is accident by a group of middle managers from across the Agency. The vision of One NASA is accident by a group of middle managers from across the Agency. The vision of One NASA is accident by a group of middle managers from across the Agency. The vision of One NASA is accident by a group of middle managers from across the Agency. The vision of One NASA is accident by a group of middle managers from across the Agency. The vision of One NASA is accident by a group of middle managers from across the Agency. The vision of One NASA is for a more cohesive, collaborative, and less bureaucratic Agency.for a more cohesive, collaborative, and less bureaucratic Agency.for a more cohesive, collaborative, and less bureaucratic Agency.for a more cohesive, collaborative, and less bureaucratic Agency.for a more cohesive, collaborative, and less bureaucratic Agency.for a more cohesive, collaborative, and less bureaucratic Agency.for a more cohesive, collaborative, and less bureaucratic Agency.for a more cohesive, collaborative, and less bureaucratic Agency.for a more cohesive, collaborative, and less bureaucratic Agency.for a more cohesive, collaborative, and less bureaucratic Agency.

6

of members of NASA̓ s Senior Leadership Council led by Mr. Al of members of NASA̓ s Senior Leadership Council led by Mr. Al of members of NASA̓ s Senior Leadership Council led by Mr. Al of members of NASA̓ s Senior Leadership Council led by Mr. Al of members of NASA̓ s Senior Leadership Council led by Mr. Al of members of NASA̓ s Senior Leadership Council led by Mr. Al of members of NASA̓ s Senior Leadership Council led by Mr. Al of members of NASA̓ s Senior Leadership Council led by Mr. Al of members of NASA̓ s Senior Leadership Council led by Mr. Al of members of NASA̓ s Senior Leadership Council led by Mr. Al of members of NASA̓ s Senior Leadership Council led by Mr. Al of members of NASA̓ s Senior Leadership Council led by Mr. Al Diaz, Director of the Goddard Space Flight Center. It has also Diaz, Director of the Goddard Space Flight Center. It has also Diaz, Director of the Goddard Space Flight Center. It has also Diaz, Director of the Goddard Space Flight Center. It has also Diaz, Director of the Goddard Space Flight Center. It has also Diaz, Director of the Goddard Space Flight Center. It has also Diaz, Director of the Goddard Space Flight Center. It has also Diaz, Director of the Goddard Space Flight Center. It has also Diaz, Director of the Goddard Space Flight Center. It has also Diaz, Director of the Goddard Space Flight Center. It has also Diaz, Director of the Goddard Space Flight Center. It has also Diaz, Director of the Goddard Space Flight Center. It has also been their assignment to spell out a specifi c course of actions to been their assignment to spell out a specifi c course of actions to been their assignment to spell out a specifi c course of actions to been their assignment to spell out a specifi c course of actions to been their assignment to spell out a specifi c course of actions to been their assignment to spell out a specifi c course of actions to been their assignment to spell out a specifi c course of actions to been their assignment to spell out a specifi c course of actions to been their assignment to spell out a specifi c course of actions to been their assignment to spell out a specifi c course of actions to been their assignment to spell out a specifi c course of actions to been their assignment to spell out a specifi c course of actions to been their assignment to spell out a specifi c course of actions to accomplish what has been called for. Other members of what has accomplish what has been called for. Other members of what has accomplish what has been called for. Other members of what has accomplish what has been called for. Other members of what has accomplish what has been called for. Other members of what has accomplish what has been called for. Other members of what has accomplish what has been called for. Other members of what has accomplish what has been called for. Other members of what has accomplish what has been called for. Other members of what has accomplish what has been called for. Other members of what has accomplish what has been called for. Other members of what has accomplish what has been called for. Other members of what has come to be called the Diaz Team include: Dr. Ghassem Asrar, come to be called the Diaz Team include: Dr. Ghassem Asrar, come to be called the Diaz Team include: Dr. Ghassem Asrar, come to be called the Diaz Team include: Dr. Ghassem Asrar, come to be called the Diaz Team include: Dr. Ghassem Asrar, come to be called the Diaz Team include: Dr. Ghassem Asrar, come to be called the Diaz Team include: Dr. Ghassem Asrar, come to be called the Diaz Team include: Dr. Ghassem Asrar, come to be called the Diaz Team include: Dr. Ghassem Asrar, come to be called the Diaz Team include: Dr. Ghassem Asrar, come to be called the Diaz Team include: Dr. Ghassem Asrar, come to be called the Diaz Team include: Dr. Ghassem Asrar, come to be called the Diaz Team include: Dr. Ghassem Asrar, Associate Administrator for Earth Sciences, NASA Headquar-Associate Administrator for Earth Sciences, NASA Headquar-Associate Administrator for Earth Sciences, NASA Headquar-Associate Administrator for Earth Sciences, NASA Headquar-Associate Administrator for Earth Sciences, NASA Headquar-Associate Administrator for Earth Sciences, NASA Headquar-Associate Administrator for Earth Sciences, NASA Headquar-Associate Administrator for Earth Sciences, NASA Headquar-Associate Administrator for Earth Sciences, NASA Headquar-Associate Administrator for Earth Sciences, NASA Headquar-Associate Administrator for Earth Sciences, NASA Headquar-Associate Administrator for Earth Sciences, NASA Headquar-ters; Dr. Julian Earls, Director, Glenn Research Center; Mr. Scott ters; Dr. Julian Earls, Director, Glenn Research Center; Mr. Scott ters; Dr. Julian Earls, Director, Glenn Research Center; Mr. Scott ters; Dr. Julian Earls, Director, Glenn Research Center; Mr. Scott ters; Dr. Julian Earls, Director, Glenn Research Center; Mr. Scott ters; Dr. Julian Earls, Director, Glenn Research Center; Mr. Scott ters; Dr. Julian Earls, Director, Glenn Research Center; Mr. Scott ters; Dr. Julian Earls, Director, Glenn Research Center; Mr. Scott ters; Dr. Julian Earls, Director, Glenn Research Center; Mr. Scott ters; Dr. Julian Earls, Director, Glenn Research Center; Mr. Scott ters; Dr. Julian Earls, Director, Glenn Research Center; Mr. Scott ters; Dr. Julian Earls, Director, Glenn Research Center; Mr. Scott ters; Dr. Julian Earls, Director, Glenn Research Center; Mr. Scott Hubbard, Director, Ames Research Center; Mr. James Kennedy, Hubbard, Director, Ames Research Center; Mr. James Kennedy, Hubbard, Director, Ames Research Center; Mr. James Kennedy, Hubbard, Director, Ames Research Center; Mr. James Kennedy, Hubbard, Director, Ames Research Center; Mr. James Kennedy, Hubbard, Director, Ames Research Center; Mr. James Kennedy, Hubbard, Director, Ames Research Center; Mr. James Kennedy, Hubbard, Director, Ames Research Center; Mr. James Kennedy, Hubbard, Director, Ames Research Center; Mr. James Kennedy, Hubbard, Director, Ames Research Center; Mr. James Kennedy, Hubbard, Director, Ames Research Center; Mr. James Kennedy, Hubbard, Director, Ames Research Center; Mr. James Kennedy, Director, Kennedy Space Center; and Ms. Vicki Novak, Assistant Director, Kennedy Space Center; and Ms. Vicki Novak, Assistant Director, Kennedy Space Center; and Ms. Vicki Novak, Assistant Director, Kennedy Space Center; and Ms. Vicki Novak, Assistant Director, Kennedy Space Center; and Ms. Vicki Novak, Assistant Director, Kennedy Space Center; and Ms. Vicki Novak, Assistant Director, Kennedy Space Center; and Ms. Vicki Novak, Assistant Director, Kennedy Space Center; and Ms. Vicki Novak, Assistant Director, Kennedy Space Center; and Ms. Vicki Novak, Assistant Director, Kennedy Space Center; and Ms. Vicki Novak, Assistant Director, Kennedy Space Center; and Ms. Vicki Novak, Assistant Director, Kennedy Space Center; and Ms. Vicki Novak, Assistant Administrator for Human Resources, NASA Headquarters.Administrator for Human Resources, NASA Headquarters.Administrator for Human Resources, NASA Headquarters.Administrator for Human Resources, NASA Headquarters.Administrator for Human Resources, NASA Headquarters.Administrator for Human Resources, NASA Headquarters.Administrator for Human Resources, NASA Headquarters.Administrator for Human Resources, NASA Headquarters.Administrator for Human Resources, NASA Headquarters.Administrator for Human Resources, NASA Headquarters.Administrator for Human Resources, NASA Headquarters.Administrator for Human Resources, NASA Headquarters.

The Organizational Cause Statement in the CAIB Report The Organizational Cause Statement in the CAIB Report The Organizational Cause Statement in the CAIB Report The Organizational Cause Statement in the CAIB Report The Organizational Cause Statement in the CAIB Report The Organizational Cause Statement in the CAIB Report The Organizational Cause Statement in the CAIB Report The Organizational Cause Statement in the CAIB Report The Organizational Cause Statement in the CAIB Report The Organizational Cause Statement in the CAIB Report The Organizational Cause Statement in the CAIB Report The Organizational Cause Statement in the CAIB Report The Organizational Cause Statement in the CAIB Report guided the Teamʼs deliberations from the beginning. The Team, guided the Teamʼs deliberations from the beginning. The Team, guided the Teamʼs deliberations from the beginning. The Team, guided the Teamʼs deliberations from the beginning. The Team, guided the Teamʼs deliberations from the beginning. The Team, guided the Teamʼs deliberations from the beginning. The Team, guided the Teamʼs deliberations from the beginning. The Team, guided the Teamʼs deliberations from the beginning. The Team, guided the Teamʼs deliberations from the beginning. The Team, guided the Teamʼs deliberations from the beginning. The Team, guided the Teamʼs deliberations from the beginning. The Team, guided the Teamʼs deliberations from the beginning. The Team, therefore, determined that all R-O-Fs that dealt directly or in-therefore, determined that all R-O-Fs that dealt directly or in-therefore, determined that all R-O-Fs that dealt directly or in-therefore, determined that all R-O-Fs that dealt directly or in-therefore, determined that all R-O-Fs that dealt directly or in-therefore, determined that all R-O-Fs that dealt directly or in-therefore, determined that all R-O-Fs that dealt directly or in-therefore, determined that all R-O-Fs that dealt directly or in-therefore, determined that all R-O-Fs that dealt directly or in-therefore, determined that all R-O-Fs that dealt directly or in-therefore, determined that all R-O-Fs that dealt directly or in-therefore, determined that all R-O-Fs that dealt directly or in-therefore, determined that all R-O-Fs that dealt directly or in-directly with organizational behaviors that might have a bear-directly with organizational behaviors that might have a bear-directly with organizational behaviors that might have a bear-directly with organizational behaviors that might have a bear-directly with organizational behaviors that might have a bear-directly with organizational behaviors that might have a bear-directly with organizational behaviors that might have a bear-directly with organizational behaviors that might have a bear-directly with organizational behaviors that might have a bear-directly with organizational behaviors that might have a bear-directly with organizational behaviors that might have a bear-directly with organizational behaviors that might have a bear-ing on safety or mission success would be identifi ed as having ing on safety or mission success would be identifi ed as having ing on safety or mission success would be identifi ed as having ing on safety or mission success would be identifi ed as having ing on safety or mission success would be identifi ed as having ing on safety or mission success would be identifi ed as having ing on safety or mission success would be identifi ed as having ing on safety or mission success would be identifi ed as having ing on safety or mission success would be identifi ed as having ing on safety or mission success would be identifi ed as having ing on safety or mission success would be identifi ed as having ing on safety or mission success would be identifi ed as having ing on safety or mission success would be identifi ed as having Agency-wide applicability. In addition, the Team has worked Agency-wide applicability. In addition, the Team has worked Agency-wide applicability. In addition, the Team has worked Agency-wide applicability. In addition, the Team has worked Agency-wide applicability. In addition, the Team has worked Agency-wide applicability. In addition, the Team has worked Agency-wide applicability. In addition, the Team has worked Agency-wide applicability. In addition, the Team has worked Agency-wide applicability. In addition, the Team has worked Agency-wide applicability. In addition, the Team has worked Agency-wide applicability. In addition, the Team has worked Agency-wide applicability. In addition, the Team has worked to assure that its Report would be understood and accepted by to assure that its Report would be understood and accepted by to assure that its Report would be understood and accepted by to assure that its Report would be understood and accepted by to assure that its Report would be understood and accepted by to assure that its Report would be understood and accepted by to assure that its Report would be understood and accepted by to assure that its Report would be understood and accepted by to assure that its Report would be understood and accepted by to assure that its Report would be understood and accepted by to assure that its Report would be understood and accepted by to assure that its Report would be understood and accepted by the NASA workforce. With that objective in mind, the Team the NASA workforce. With that objective in mind, the Team the NASA workforce. With that objective in mind, the Team the NASA workforce. With that objective in mind, the Team the NASA workforce. With that objective in mind, the Team the NASA workforce. With that objective in mind, the Team the NASA workforce. With that objective in mind, the Team the NASA workforce. With that objective in mind, the Team the NASA workforce. With that objective in mind, the Team the NASA workforce. With that objective in mind, the Team the NASA workforce. With that objective in mind, the Team the NASA workforce. With that objective in mind, the Team the NASA workforce. With that objective in mind, the Team established a work plan at its fi rst meeting in September 2003 established a work plan at its fi rst meeting in September 2003 established a work plan at its fi rst meeting in September 2003 established a work plan at its fi rst meeting in September 2003 established a work plan at its fi rst meeting in September 2003 established a work plan at its fi rst meeting in September 2003 established a work plan at its fi rst meeting in September 2003 established a work plan at its fi rst meeting in September 2003 established a work plan at its fi rst meeting in September 2003 established a work plan at its fi rst meeting in September 2003 established a work plan at its fi rst meeting in September 2003 established a work plan at its fi rst meeting in September 2003 that allowed for extensive Agency review of all that the Team that allowed for extensive Agency review of all that the Team that allowed for extensive Agency review of all that the Team that allowed for extensive Agency review of all that the Team that allowed for extensive Agency review of all that the Team that allowed for extensive Agency review of all that the Team that allowed for extensive Agency review of all that the Team that allowed for extensive Agency review of all that the Team that allowed for extensive Agency review of all that the Team that allowed for extensive Agency review of all that the Team that allowed for extensive Agency review of all that the Team that allowed for extensive Agency review of all that the Team that allowed for extensive Agency review of all that the Team produced. Figure 1 outlines that plan. The fi rst product the produced. Figure 1 outlines that plan. The fi rst product the produced. Figure 1 outlines that plan. The fi rst product the produced. Figure 1 outlines that plan. The fi rst product the produced. Figure 1 outlines that plan. The fi rst product the produced. Figure 1 outlines that plan. The fi rst product the produced. Figure 1 outlines that plan. The fi rst product the produced. Figure 1 outlines that plan. The fi rst product the produced. Figure 1 outlines that plan. The fi rst product the produced. Figure 1 outlines that plan. The fi rst product the produced. Figure 1 outlines that plan. The fi rst product the produced. Figure 1 outlines that plan. The fi rst product the Diaz Team developed and distributed was the CAIB Agency Diaz Team developed and distributed was the CAIB Agency Diaz Team developed and distributed was the CAIB Agency Diaz Team developed and distributed was the CAIB Agency Diaz Team developed and distributed was the CAIB Agency Diaz Team developed and distributed was the CAIB Agency Diaz Team developed and distributed was the CAIB Agency Diaz Team developed and distributed was the CAIB Agency Diaz Team developed and distributed was the CAIB Agency Diaz Team developed and distributed was the CAIB Agency Diaz Team developed and distributed was the CAIB Agency Diaz Team developed and distributed was the CAIB Agency Diaz Team developed and distributed was the CAIB Agency Wide Action Matrix, hereafter referred to as the Diaz Team Wide Action Matrix, hereafter referred to as the Diaz Team Wide Action Matrix, hereafter referred to as the Diaz Team Wide Action Matrix, hereafter referred to as the Diaz Team Wide Action Matrix, hereafter referred to as the Diaz Team Wide Action Matrix, hereafter referred to as the Diaz Team Wide Action Matrix, hereafter referred to as the Diaz Team Wide Action Matrix, hereafter referred to as the Diaz Team Wide Action Matrix, hereafter referred to as the Diaz Team Wide Action Matrix, hereafter referred to as the Diaz Team Wide Action Matrix, hereafter referred to as the Diaz Team Wide Action Matrix, hereafter referred to as the Diaz Team Matrix, which is included as an appendix in the Report. The Matrix, which is included as an appendix in the Report. The Matrix, which is included as an appendix in the Report. The Matrix, which is included as an appendix in the Report. The Matrix, which is included as an appendix in the Report. The Matrix, which is included as an appendix in the Report. The Matrix, which is included as an appendix in the Report. The Matrix, which is included as an appendix in the Report. The Matrix, which is included as an appendix in the Report. The Matrix, which is included as an appendix in the Report. The Matrix, which is included as an appendix in the Report. The Matrix, which is included as an appendix in the Report. The Diaz Team Matrix is in a tabular format that identifi es which Diaz Team Matrix is in a tabular format that identifi es which Diaz Team Matrix is in a tabular format that identifi es which Diaz Team Matrix is in a tabular format that identifi es which Diaz Team Matrix is in a tabular format that identifi es which Diaz Team Matrix is in a tabular format that identifi es which Diaz Team Matrix is in a tabular format that identifi es which Diaz Team Matrix is in a tabular format that identifi es which Diaz Team Matrix is in a tabular format that identifi es which Diaz Team Matrix is in a tabular format that identifi es which Diaz Team Matrix is in a tabular format that identifi es which Diaz Team Matrix is in a tabular format that identifi es which R-O-Fs are broadly applicable. The entry for each R-O-F pro-R-O-Fs are broadly applicable. The entry for each R-O-F pro-R-O-Fs are broadly applicable. The entry for each R-O-F pro-R-O-Fs are broadly applicable. The entry for each R-O-F pro-R-O-Fs are broadly applicable. The entry for each R-O-F pro-R-O-Fs are broadly applicable. The entry for each R-O-F pro-R-O-Fs are broadly applicable. The entry for each R-O-F pro-R-O-Fs are broadly applicable. The entry for each R-O-F pro-R-O-Fs are broadly applicable. The entry for each R-O-F pro-R-O-Fs are broadly applicable. The entry for each R-O-F pro-R-O-Fs are broadly applicable. The entry for each R-O-F pro-R-O-Fs are broadly applicable. The entry for each R-O-F pro-vides a rationale for including it and recommends a set of actions vides a rationale for including it and recommends a set of actions vides a rationale for including it and recommends a set of actions vides a rationale for including it and recommends a set of actions vides a rationale for including it and recommends a set of actions vides a rationale for including it and recommends a set of actions vides a rationale for including it and recommends a set of actions vides a rationale for including it and recommends a set of actions vides a rationale for including it and recommends a set of actions vides a rationale for including it and recommends a set of actions vides a rationale for including it and recommends a set of actions vides a rationale for including it and recommends a set of actions vides a rationale for including it and recommends a set of actions to address it. The Diaz Team Matrix went through a series of to address it. The Diaz Team Matrix went through a series of to address it. The Diaz Team Matrix went through a series of to address it. The Diaz Team Matrix went through a series of to address it. The Diaz Team Matrix went through a series of to address it. The Diaz Team Matrix went through a series of to address it. The Diaz Team Matrix went through a series of to address it. The Diaz Team Matrix went through a series of to address it. The Diaz Team Matrix went through a series of to address it. The Diaz Team Matrix went through a series of to address it. The Diaz Team Matrix went through a series of to address it. The Diaz Team Matrix went through a series of reviews, fi rst by Diaz Team members, and then by NASA senior reviews, fi rst by Diaz Team members, and then by NASA senior reviews, fi rst by Diaz Team members, and then by NASA senior reviews, fi rst by Diaz Team members, and then by NASA senior reviews, fi rst by Diaz Team members, and then by NASA senior reviews, fi rst by Diaz Team members, and then by NASA senior reviews, fi rst by Diaz Team members, and then by NASA senior reviews, fi rst by Diaz Team members, and then by NASA senior reviews, fi rst by Diaz Team members, and then by NASA senior reviews, fi rst by Diaz Team members, and then by NASA senior reviews, fi rst by Diaz Team members, and then by NASA senior reviews, fi rst by Diaz Team members, and then by NASA senior reviews, fi rst by Diaz Team members, and then by NASA senior management. To facilitate discussions during Safety and Mis-management. To facilitate discussions during Safety and Mis-management. To facilitate discussions during Safety and Mis-management. To facilitate discussions during Safety and Mis-management. To facilitate discussions during Safety and Mis-management. To facilitate discussions during Safety and Mis-management. To facilitate discussions during Safety and Mis-management. To facilitate discussions during Safety and Mis-management. To facilitate discussions during Safety and Mis-management. To facilitate discussions during Safety and Mis-management. To facilitate discussions during Safety and Mis-management. To facilitate discussions during Safety and Mis-sion Success Week, the matrix was then distributed to more than sion Success Week, the matrix was then distributed to more than sion Success Week, the matrix was then distributed to more than sion Success Week, the matrix was then distributed to more than sion Success Week, the matrix was then distributed to more than sion Success Week, the matrix was then distributed to more than sion Success Week, the matrix was then distributed to more than sion Success Week, the matrix was then distributed to more than sion Success Week, the matrix was then distributed to more than sion Success Week, the matrix was then distributed to more than sion Success Week, the matrix was then distributed to more than sion Success Week, the matrix was then distributed to more than sion Success Week, the matrix was then distributed to more than 65,000 members of the NASA workforce, both civil service and 65,000 members of the NASA workforce, both civil service and 65,000 members of the NASA workforce, both civil service and 65,000 members of the NASA workforce, both civil service and 65,000 members of the NASA workforce, both civil service and 65,000 members of the NASA workforce, both civil service and 65,000 members of the NASA workforce, both civil service and 65,000 members of the NASA workforce, both civil service and 65,000 members of the NASA workforce, both civil service and 65,000 members of the NASA workforce, both civil service and 65,000 members of the NASA workforce, both civil service and 65,000 members of the NASA workforce, both civil service and

contractor employees. The resulting feedback was outstanding contractor employees. The resulting feedback was outstanding contractor employees. The resulting feedback was outstanding contractor employees. The resulting feedback was outstanding contractor employees. The resulting feedback was outstanding contractor employees. The resulting feedback was outstanding contractor employees. The resulting feedback was outstanding contractor employees. The resulting feedback was outstanding contractor employees. The resulting feedback was outstanding contractor employees. The resulting feedback was outstanding contractor employees. The resulting feedback was outstanding in both quantity and quality. A thorough review of those many in both quantity and quality. A thorough review of those many in both quantity and quality. A thorough review of those many in both quantity and quality. A thorough review of those many in both quantity and quality. A thorough review of those many in both quantity and quality. A thorough review of those many in both quantity and quality. A thorough review of those many in both quantity and quality. A thorough review of those many in both quantity and quality. A thorough review of those many in both quantity and quality. A thorough review of those many in both quantity and quality. A thorough review of those many thoughtful comments showed that an overwhelming majority thoughtful comments showed that an overwhelming majority thoughtful comments showed that an overwhelming majority thoughtful comments showed that an overwhelming majority thoughtful comments showed that an overwhelming majority thoughtful comments showed that an overwhelming majority thoughtful comments showed that an overwhelming majority thoughtful comments showed that an overwhelming majority thoughtful comments showed that an overwhelming majority thoughtful comments showed that an overwhelming majority thoughtful comments showed that an overwhelming majority thoughtful comments showed that an overwhelming majority served to validate both the CAIB evaluation of NASA and the served to validate both the CAIB evaluation of NASA and the served to validate both the CAIB evaluation of NASA and the served to validate both the CAIB evaluation of NASA and the served to validate both the CAIB evaluation of NASA and the served to validate both the CAIB evaluation of NASA and the served to validate both the CAIB evaluation of NASA and the served to validate both the CAIB evaluation of NASA and the served to validate both the CAIB evaluation of NASA and the served to validate both the CAIB evaluation of NASA and the served to validate both the CAIB evaluation of NASA and the Diaz Team Matrix. With the help of the One NASA Team, the Diaz Team Matrix. With the help of the One NASA Team, the Diaz Team Matrix. With the help of the One NASA Team, the Diaz Team Matrix. With the help of the One NASA Team, the Diaz Team Matrix. With the help of the One NASA Team, the Diaz Team Matrix. With the help of the One NASA Team, the Diaz Team Matrix. With the help of the One NASA Team, the Diaz Team Matrix. With the help of the One NASA Team, the Diaz Team Matrix. With the help of the One NASA Team, the Diaz Team Matrix. With the help of the One NASA Team, the Diaz Team Matrix. With the help of the One NASA Team, the Diaz Team Matrix. With the help of the One NASA Team, the Diaz Team organized the Agency-wide feedback and the Diaz Diaz Team organized the Agency-wide feedback and the Diaz Diaz Team organized the Agency-wide feedback and the Diaz Diaz Team organized the Agency-wide feedback and the Diaz Diaz Team organized the Agency-wide feedback and the Diaz Diaz Team organized the Agency-wide feedback and the Diaz Diaz Team organized the Agency-wide feedback and the Diaz Diaz Team organized the Agency-wide feedback and the Diaz Diaz Team organized the Agency-wide feedback and the Diaz Diaz Team organized the Agency-wide feedback and the Diaz Diaz Team organized the Agency-wide feedback and the Diaz Team Matrix itself into distinct categories, which is discussed Team Matrix itself into distinct categories, which is discussed Team Matrix itself into distinct categories, which is discussed Team Matrix itself into distinct categories, which is discussed Team Matrix itself into distinct categories, which is discussed Team Matrix itself into distinct categories, which is discussed Team Matrix itself into distinct categories, which is discussed Team Matrix itself into distinct categories, which is discussed Team Matrix itself into distinct categories, which is discussed Team Matrix itself into distinct categories, which is discussed Team Matrix itself into distinct categories, which is discussed Team Matrix itself into distinct categories, which is discussed throughout the Report.throughout the Report.throughout the Report.throughout the Report.

The Team identifi ed 85 R-O-Fs that it determined to have The Team identifi ed 85 R-O-Fs that it determined to have The Team identifi ed 85 R-O-Fs that it determined to have The Team identifi ed 85 R-O-Fs that it determined to have The Team identifi ed 85 R-O-Fs that it determined to have The Team identifi ed 85 R-O-Fs that it determined to have The Team identifi ed 85 R-O-Fs that it determined to have The Team identifi ed 85 R-O-Fs that it determined to have The Team identifi ed 85 R-O-Fs that it determined to have The Team identifi ed 85 R-O-Fs that it determined to have The Team identifi ed 85 R-O-Fs that it determined to have The Team identifi ed 85 R-O-Fs that it determined to have Agency-wide applicability. (See Figure 2.) The Team developed Agency-wide applicability. (See Figure 2.) The Team developed Agency-wide applicability. (See Figure 2.) The Team developed Agency-wide applicability. (See Figure 2.) The Team developed Agency-wide applicability. (See Figure 2.) The Team developed Agency-wide applicability. (See Figure 2.) The Team developed Agency-wide applicability. (See Figure 2.) The Team developed Agency-wide applicability. (See Figure 2.) The Team developed Agency-wide applicability. (See Figure 2.) The Team developed Agency-wide applicability. (See Figure 2.) The Team developed Agency-wide applicability. (See Figure 2.) The Team developed 40 “Specifi c Actions” for NASA to take in order to meet the 40 “Specifi c Actions” for NASA to take in order to meet the 40 “Specifi c Actions” for NASA to take in order to meet the 40 “Specifi c Actions” for NASA to take in order to meet the 40 “Specifi c Actions” for NASA to take in order to meet the 40 “Specifi c Actions” for NASA to take in order to meet the 40 “Specifi c Actions” for NASA to take in order to meet the 40 “Specifi c Actions” for NASA to take in order to meet the 40 “Specifi c Actions” for NASA to take in order to meet the 40 “Specifi c Actions” for NASA to take in order to meet the 40 “Specifi c Actions” for NASA to take in order to meet the 40 “Specifi c Actions” for NASA to take in order to meet the requirements contained in those R-O-Fs. Each action consists of requirements contained in those R-O-Fs. Each action consists of requirements contained in those R-O-Fs. Each action consists of requirements contained in those R-O-Fs. Each action consists of requirements contained in those R-O-Fs. Each action consists of requirements contained in those R-O-Fs. Each action consists of requirements contained in those R-O-Fs. Each action consists of requirements contained in those R-O-Fs. Each action consists of requirements contained in those R-O-Fs. Each action consists of requirements contained in those R-O-Fs. Each action consists of requirements contained in those R-O-Fs. Each action consists of multiple tasks and requires a detailed implementation plan. Each multiple tasks and requires a detailed implementation plan. Each multiple tasks and requires a detailed implementation plan. Each multiple tasks and requires a detailed implementation plan. Each multiple tasks and requires a detailed implementation plan. Each multiple tasks and requires a detailed implementation plan. Each multiple tasks and requires a detailed implementation plan. Each multiple tasks and requires a detailed implementation plan. Each multiple tasks and requires a detailed implementation plan. Each multiple tasks and requires a detailed implementation plan. Each multiple tasks and requires a detailed implementation plan. Each multiple tasks and requires a detailed implementation plan. Each action has been assigned a NASA Headquarters code, signifying action has been assigned a NASA Headquarters code, signifying action has been assigned a NASA Headquarters code, signifying action has been assigned a NASA Headquarters code, signifying action has been assigned a NASA Headquarters code, signifying action has been assigned a NASA Headquarters code, signifying action has been assigned a NASA Headquarters code, signifying action has been assigned a NASA Headquarters code, signifying action has been assigned a NASA Headquarters code, signifying action has been assigned a NASA Headquarters code, signifying action has been assigned a NASA Headquarters code, signifying which organization has primary responsibility for implementing which organization has primary responsibility for implementing which organization has primary responsibility for implementing which organization has primary responsibility for implementing which organization has primary responsibility for implementing which organization has primary responsibility for implementing which organization has primary responsibility for implementing which organization has primary responsibility for implementing which organization has primary responsibility for implementing which organization has primary responsibility for implementing which organization has primary responsibility for implementing which organization has primary responsibility for implementing that action. Figure 3 shows the distribution of the actions across that action. Figure 3 shows the distribution of the actions across that action. Figure 3 shows the distribution of the actions across that action. Figure 3 shows the distribution of the actions across that action. Figure 3 shows the distribution of the actions across that action. Figure 3 shows the distribution of the actions across that action. Figure 3 shows the distribution of the actions across that action. Figure 3 shows the distribution of the actions across that action. Figure 3 shows the distribution of the actions across that action. Figure 3 shows the distribution of the actions across that action. Figure 3 shows the distribution of the actions across seven Headquarters organizations. seven Headquarters organizations. seven Headquarters organizations. seven Headquarters organizations. seven Headquarters organizations. seven Headquarters organizations.

In addition, the Team has identifi ed a limited number of “Diaz In addition, the Team has identifi ed a limited number of “Diaz In addition, the Team has identifi ed a limited number of “Diaz In addition, the Team has identifi ed a limited number of “Diaz In addition, the Team has identifi ed a limited number of “Diaz In addition, the Team has identifi ed a limited number of “Diaz In addition, the Team has identifi ed a limited number of “Diaz In addition, the Team has identifi ed a limited number of “Diaz In addition, the Team has identifi ed a limited number of “Diaz In addition, the Team has identifi ed a limited number of “Diaz In addition, the Team has identifi ed a limited number of “Diaz Team Goals.” Given the broad nature of these goals, the Diaz Team Goals.” Given the broad nature of these goals, the Diaz Team Goals.” Given the broad nature of these goals, the Diaz Team Goals.” Given the broad nature of these goals, the Diaz Team Goals.” Given the broad nature of these goals, the Diaz Team Goals.” Given the broad nature of these goals, the Diaz Team Goals.” Given the broad nature of these goals, the Diaz Team Goals.” Given the broad nature of these goals, the Diaz Team Goals.” Given the broad nature of these goals, the Diaz Team Goals.” Given the broad nature of these goals, the Diaz Team Goals.” Given the broad nature of these goals, the Diaz Team Goals.” Given the broad nature of these goals, the Diaz Team has not made a specifi c suggestion with respect to as-Team has not made a specifi c suggestion with respect to as-Team has not made a specifi c suggestion with respect to as-Team has not made a specifi c suggestion with respect to as-Team has not made a specifi c suggestion with respect to as-Team has not made a specifi c suggestion with respect to as-Team has not made a specifi c suggestion with respect to as-Team has not made a specifi c suggestion with respect to as-Team has not made a specifi c suggestion with respect to as-Team has not made a specifi c suggestion with respect to as-Team has not made a specifi c suggestion with respect to as-signing responsibility for their implementation. However, it is signing responsibility for their implementation. However, it is signing responsibility for their implementation. However, it is signing responsibility for their implementation. However, it is signing responsibility for their implementation. However, it is signing responsibility for their implementation. However, it is signing responsibility for their implementation. However, it is signing responsibility for their implementation. However, it is signing responsibility for their implementation. However, it is signing responsibility for their implementation. However, it is signing responsibility for their implementation. However, it is signing responsibility for their implementation. However, it is expected that the Agency would respond to these goals in sub-expected that the Agency would respond to these goals in sub-expected that the Agency would respond to these goals in sub-expected that the Agency would respond to these goals in sub-expected that the Agency would respond to these goals in sub-expected that the Agency would respond to these goals in sub-expected that the Agency would respond to these goals in sub-expected that the Agency would respond to these goals in sub-expected that the Agency would respond to these goals in sub-expected that the Agency would respond to these goals in sub-expected that the Agency would respond to these goals in sub-sequent planning.sequent planning.sequent planning.

Beyond these 85 R-O-Fs, it was recognized that while the re-Beyond these 85 R-O-Fs, it was recognized that while the re-Beyond these 85 R-O-Fs, it was recognized that while the re-Beyond these 85 R-O-Fs, it was recognized that while the re-Beyond these 85 R-O-Fs, it was recognized that while the re-Beyond these 85 R-O-Fs, it was recognized that while the re-Beyond these 85 R-O-Fs, it was recognized that while the re-Beyond these 85 R-O-Fs, it was recognized that while the re-Beyond these 85 R-O-Fs, it was recognized that while the re-Beyond these 85 R-O-Fs, it was recognized that while the re-Beyond these 85 R-O-Fs, it was recognized that while the re-maining elements might not have Agency-wide applicability, maining elements might not have Agency-wide applicability, maining elements might not have Agency-wide applicability, maining elements might not have Agency-wide applicability, maining elements might not have Agency-wide applicability, maining elements might not have Agency-wide applicability, maining elements might not have Agency-wide applicability, maining elements might not have Agency-wide applicability, maining elements might not have Agency-wide applicability, maining elements might not have Agency-wide applicability, maining elements might not have Agency-wide applicability, maining elements might not have Agency-wide applicability, they might have applicability outside the Human Space Flight they might have applicability outside the Human Space Flight they might have applicability outside the Human Space Flight they might have applicability outside the Human Space Flight they might have applicability outside the Human Space Flight they might have applicability outside the Human Space Flight they might have applicability outside the Human Space Flight they might have applicability outside the Human Space Flight they might have applicability outside the Human Space Flight they might have applicability outside the Human Space Flight they might have applicability outside the Human Space Flight Program and therefore should not be overlooked. Individual or-Program and therefore should not be overlooked. Individual or-Program and therefore should not be overlooked. Individual or-Program and therefore should not be overlooked. Individual or-Program and therefore should not be overlooked. Individual or-Program and therefore should not be overlooked. Individual or-Program and therefore should not be overlooked. Individual or-Program and therefore should not be overlooked. Individual or-Program and therefore should not be overlooked. Individual or-Program and therefore should not be overlooked. Individual or-Program and therefore should not be overlooked. Individual or-Program and therefore should not be overlooked. Individual or-ganizations may very well fi nd that some have bearing on their ganizations may very well fi nd that some have bearing on their ganizations may very well fi nd that some have bearing on their ganizations may very well fi nd that some have bearing on their ganizations may very well fi nd that some have bearing on their ganizations may very well fi nd that some have bearing on their ganizations may very well fi nd that some have bearing on their ganizations may very well fi nd that some have bearing on their ganizations may very well fi nd that some have bearing on their ganizations may very well fi nd that some have bearing on their ganizations may very well fi nd that some have bearing on their projects. This will be especially true for programs that conduct projects. This will be especially true for programs that conduct projects. This will be especially true for programs that conduct projects. This will be especially true for programs that conduct projects. This will be especially true for programs that conduct projects. This will be especially true for programs that conduct projects. This will be especially true for programs that conduct projects. This will be especially true for programs that conduct projects. This will be especially true for programs that conduct projects. This will be especially true for programs that conduct projects. This will be especially true for programs that conduct projects. This will be especially true for programs that conduct aircraft operations or support development of new aerospace aircraft operations or support development of new aerospace aircraft operations or support development of new aerospace aircraft operations or support development of new aerospace aircraft operations or support development of new aerospace aircraft operations or support development of new aerospace aircraft operations or support development of new aerospace aircraft operations or support development of new aerospace aircraft operations or support development of new aerospace aircraft operations or support development of new aerospace aircraft operations or support development of new aerospace

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

Multiple Iterations& Reviews with Diaz Team,

HQ Codes, & Center Directors

Release DraftDiaz Team Matrix

For Review

Assemble Team&

Define Requirements

Analysis ToIdentify Broadly

Applicable R-O-Fs

Compile &Evaluate

Safety & MissionSuccess Week

Feedback

Release Draft forSafety & MissionSuccess Week

Release DiazTeam ReportJanuary 2004

Develop Actions& Assign

Responsibilities

Release Diaz Team Report Draft for Review

7

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

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

8

vehicles such as the Next-Generation Vehicle or next-generation vehicles such as the Next-Generation Vehicle or next-generation vehicles such as the Next-Generation Vehicle or next-generation vehicles such as the Next-Generation Vehicle or next-generation vehicles such as the Next-Generation Vehicle or next-generation vehicles such as the Next-Generation Vehicle or next-generation vehicles such as the Next-Generation Vehicle or next-generation vehicles such as the Next-Generation Vehicle or next-generation vehicles such as the Next-Generation Vehicle or next-generation vehicles such as the Next-Generation Vehicle or next-generation vehicles such as the Next-Generation Vehicle or next-generation vehicles such as the Next-Generation Vehicle or next-generation vehicles such as the Next-Generation Vehicle or next-generation launch technologies. The Team encourages these organizations launch technologies. The Team encourages these organizations launch technologies. The Team encourages these organizations launch technologies. The Team encourages these organizations launch technologies. The Team encourages these organizations launch technologies. The Team encourages these organizations launch technologies. The Team encourages these organizations launch technologies. The Team encourages these organizations launch technologies. The Team encourages these organizations launch technologies. The Team encourages these organizations launch technologies. The Team encourages these organizations launch technologies. The Team encourages these organizations to address the additional R-O-Fs in the same way that the Diaz to address the additional R-O-Fs in the same way that the Diaz to address the additional R-O-Fs in the same way that the Diaz to address the additional R-O-Fs in the same way that the Diaz to address the additional R-O-Fs in the same way that the Diaz to address the additional R-O-Fs in the same way that the Diaz to address the additional R-O-Fs in the same way that the Diaz to address the additional R-O-Fs in the same way that the Diaz to address the additional R-O-Fs in the same way that the Diaz to address the additional R-O-Fs in the same way that the Diaz to address the additional R-O-Fs in the same way that the Diaz to address the additional R-O-Fs in the same way that the Diaz Team, Return to Flight (RTF) Team, and Continuing Flight Team Team, Return to Flight (RTF) Team, and Continuing Flight Team Team, Return to Flight (RTF) Team, and Continuing Flight Team Team, Return to Flight (RTF) Team, and Continuing Flight Team Team, Return to Flight (RTF) Team, and Continuing Flight Team Team, Return to Flight (RTF) Team, and Continuing Flight Team Team, Return to Flight (RTF) Team, and Continuing Flight Team Team, Return to Flight (RTF) Team, and Continuing Flight Team Team, Return to Flight (RTF) Team, and Continuing Flight Team Team, Return to Flight (RTF) Team, and Continuing Flight Team Team, Return to Flight (RTF) Team, and Continuing Flight Team Team, Return to Flight (RTF) Team, and Continuing Flight Team Team, Return to Flight (RTF) Team, and Continuing Flight Team (CFT) have done. These teams have each developed implemen-(CFT) have done. These teams have each developed implemen-(CFT) have done. These teams have each developed implemen-(CFT) have done. These teams have each developed implemen-(CFT) have done. These teams have each developed implemen-(CFT) have done. These teams have each developed implemen-(CFT) have done. These teams have each developed implemen-(CFT) have done. These teams have each developed implemen-(CFT) have done. These teams have each developed implemen-(CFT) have done. These teams have each developed implemen-(CFT) have done. These teams have each developed implemen-(CFT) have done. These teams have each developed implemen-tation plans to address the CAIB R-O-Fs. Since these plans have tation plans to address the CAIB R-O-Fs. Since these plans have tation plans to address the CAIB R-O-Fs. Since these plans have tation plans to address the CAIB R-O-Fs. Since these plans have tation plans to address the CAIB R-O-Fs. Since these plans have tation plans to address the CAIB R-O-Fs. Since these plans have tation plans to address the CAIB R-O-Fs. Since these plans have tation plans to address the CAIB R-O-Fs. Since these plans have tation plans to address the CAIB R-O-Fs. Since these plans have tation plans to address the CAIB R-O-Fs. Since these plans have tation plans to address the CAIB R-O-Fs. Since these plans have tation plans to address the CAIB R-O-Fs. Since these plans have tation plans to address the CAIB R-O-Fs. Since these plans have overlapping actions that address each R-O-F, it will be important overlapping actions that address each R-O-F, it will be important overlapping actions that address each R-O-F, it will be important overlapping actions that address each R-O-F, it will be important overlapping actions that address each R-O-F, it will be important overlapping actions that address each R-O-F, it will be important overlapping actions that address each R-O-F, it will be important overlapping actions that address each R-O-F, it will be important overlapping actions that address each R-O-F, it will be important overlapping actions that address each R-O-F, it will be important overlapping actions that address each R-O-F, it will be important overlapping actions that address each R-O-F, it will be important for NASA Headquarters to coordinate these activities. Figure 4 for NASA Headquarters to coordinate these activities. Figure 4 for NASA Headquarters to coordinate these activities. Figure 4 for NASA Headquarters to coordinate these activities. Figure 4 for NASA Headquarters to coordinate these activities. Figure 4 for NASA Headquarters to coordinate these activities. Figure 4 for NASA Headquarters to coordinate these activities. Figure 4 for NASA Headquarters to coordinate these activities. Figure 4 for NASA Headquarters to coordinate these activities. Figure 4 for NASA Headquarters to coordinate these activities. Figure 4 for NASA Headquarters to coordinate these activities. Figure 4 for NASA Headquarters to coordinate these activities. Figure 4 for NASA Headquarters to coordinate these activities. Figure 4 shows how these plans relate to each other. Specifi c expectations shows how these plans relate to each other. Specifi c expectations shows how these plans relate to each other. Specifi c expectations shows how these plans relate to each other. Specifi c expectations shows how these plans relate to each other. Specifi c expectations shows how these plans relate to each other. Specifi c expectations shows how these plans relate to each other. Specifi c expectations shows how these plans relate to each other. Specifi c expectations shows how these plans relate to each other. Specifi c expectations shows how these plans relate to each other. Specifi c expectations shows how these plans relate to each other. Specifi c expectations shows how these plans relate to each other. Specifi c expectations with respect to the development of the Renewed Commitment with respect to the development of the Renewed Commitment with respect to the development of the Renewed Commitment with respect to the development of the Renewed Commitment with respect to the development of the Renewed Commitment with respect to the development of the Renewed Commitment with respect to the development of the Renewed Commitment with respect to the development of the Renewed Commitment with respect to the development of the Renewed Commitment with respect to the development of the Renewed Commitment with respect to the development of the Renewed Commitment with respect to the development of the Renewed Commitment with respect to the development of the Renewed Commitment to Excellence Implementation Plan(s) are discussed in “Next to Excellence Implementation Plan(s) are discussed in “Next to Excellence Implementation Plan(s) are discussed in “Next to Excellence Implementation Plan(s) are discussed in “Next to Excellence Implementation Plan(s) are discussed in “Next to Excellence Implementation Plan(s) are discussed in “Next to Excellence Implementation Plan(s) are discussed in “Next to Excellence Implementation Plan(s) are discussed in “Next to Excellence Implementation Plan(s) are discussed in “Next to Excellence Implementation Plan(s) are discussed in “Next to Excellence Implementation Plan(s) are discussed in “Next to Excellence Implementation Plan(s) are discussed in “Next Steps,” Section 1.9.Steps,” Section 1.9.Steps,” Section 1.9.Steps,” Section 1.9.

The Safety and Mission Success Week provided the Diaz Team The Safety and Mission Success Week provided the Diaz Team The Safety and Mission Success Week provided the Diaz Team The Safety and Mission Success Week provided the Diaz Team The Safety and Mission Success Week provided the Diaz Team The Safety and Mission Success Week provided the Diaz Team The Safety and Mission Success Week provided the Diaz Team The Safety and Mission Success Week provided the Diaz Team The Safety and Mission Success Week provided the Diaz Team The Safety and Mission Success Week provided the Diaz Team The Safety and Mission Success Week provided the Diaz Team The Safety and Mission Success Week provided the Diaz Team with a valuable opportunity to engage the NASA workforce in with a valuable opportunity to engage the NASA workforce in with a valuable opportunity to engage the NASA workforce in with a valuable opportunity to engage the NASA workforce in with a valuable opportunity to engage the NASA workforce in with a valuable opportunity to engage the NASA workforce in with a valuable opportunity to engage the NASA workforce in with a valuable opportunity to engage the NASA workforce in with a valuable opportunity to engage the NASA workforce in with a valuable opportunity to engage the NASA workforce in with a valuable opportunity to engage the NASA workforce in with a valuable opportunity to engage the NASA workforce in with a valuable opportunity to engage the NASA workforce in its deliberations. The free exchange of views about problems and its deliberations. The free exchange of views about problems and its deliberations. The free exchange of views about problems and its deliberations. The free exchange of views about problems and its deliberations. The free exchange of views about problems and its deliberations. The free exchange of views about problems and its deliberations. The free exchange of views about problems and its deliberations. The free exchange of views about problems and its deliberations. The free exchange of views about problems and its deliberations. The free exchange of views about problems and its deliberations. The free exchange of views about problems and its deliberations. The free exchange of views about problems and proposed solutions validated the thesis that the CAIB Report had proposed solutions validated the thesis that the CAIB Report had proposed solutions validated the thesis that the CAIB Report had proposed solutions validated the thesis that the CAIB Report had proposed solutions validated the thesis that the CAIB Report had proposed solutions validated the thesis that the CAIB Report had proposed solutions validated the thesis that the CAIB Report had proposed solutions validated the thesis that the CAIB Report had proposed solutions validated the thesis that the CAIB Report had proposed solutions validated the thesis that the CAIB Report had proposed solutions validated the thesis that the CAIB Report had proposed solutions validated the thesis that the CAIB Report had proposed solutions validated the thesis that the CAIB Report had broad applicability across NASA and specifi cally the Teamʼs ap-broad applicability across NASA and specifi cally the Teamʼs ap-broad applicability across NASA and specifi cally the Teamʼs ap-broad applicability across NASA and specifi cally the Teamʼs ap-broad applicability across NASA and specifi cally the Teamʼs ap-broad applicability across NASA and specifi cally the Teamʼs ap-broad applicability across NASA and specifi cally the Teamʼs ap-broad applicability across NASA and specifi cally the Teamʼs ap-broad applicability across NASA and specifi cally the Teamʼs ap-broad applicability across NASA and specifi cally the Teamʼs ap-broad applicability across NASA and specifi cally the Teamʼs ap-broad applicability across NASA and specifi cally the Teamʼs ap-proach for addressing the R-O-Fs. The Diaz Team Report uses proach for addressing the R-O-Fs. The Diaz Team Report uses proach for addressing the R-O-Fs. The Diaz Team Report uses proach for addressing the R-O-Fs. The Diaz Team Report uses proach for addressing the R-O-Fs. The Diaz Team Report uses proach for addressing the R-O-Fs. The Diaz Team Report uses proach for addressing the R-O-Fs. The Diaz Team Report uses proach for addressing the R-O-Fs. The Diaz Team Report uses proach for addressing the R-O-Fs. The Diaz Team Report uses proach for addressing the R-O-Fs. The Diaz Team Report uses proach for addressing the R-O-Fs. The Diaz Team Report uses proach for addressing the R-O-Fs. The Diaz Team Report uses statements that are derived from Safety and Mission Success statements that are derived from Safety and Mission Success statements that are derived from Safety and Mission Success statements that are derived from Safety and Mission Success statements that are derived from Safety and Mission Success statements that are derived from Safety and Mission Success statements that are derived from Safety and Mission Success statements that are derived from Safety and Mission Success statements that are derived from Safety and Mission Success statements that are derived from Safety and Mission Success statements that are derived from Safety and Mission Success statements that are derived from Safety and Mission Success Week feedback to confi rm the Teamʼs assessments of the R-O-Week feedback to confi rm the Teamʼs assessments of the R-O-Week feedback to confi rm the Teamʼs assessments of the R-O-Week feedback to confi rm the Teamʼs assessments of the R-O-Week feedback to confi rm the Teamʼs assessments of the R-O-Week feedback to confi rm the Teamʼs assessments of the R-O-Week feedback to confi rm the Teamʼs assessments of the R-O-Week feedback to confi rm the Teamʼs assessments of the R-O-Week feedback to confi rm the Teamʼs assessments of the R-O-Week feedback to confi rm the Teamʼs assessments of the R-O-Week feedback to confi rm the Teamʼs assessments of the R-O-Week feedback to confi rm the Teamʼs assessments of the R-O-Fs, and the corresponding recommended actions. Fs, and the corresponding recommended actions. Fs, and the corresponding recommended actions. Fs, and the corresponding recommended actions. Fs, and the corresponding recommended actions. Fs, and the corresponding recommended actions. Fs, and the corresponding recommended actions. Fs, and the corresponding recommended actions. Fs, and the corresponding recommended actions. Fs, and the corresponding recommended actions.

Rather than maintain all 85 R-O-Fs as a single large group, the Rather than maintain all 85 R-O-Fs as a single large group, the Rather than maintain all 85 R-O-Fs as a single large group, the Rather than maintain all 85 R-O-Fs as a single large group, the Rather than maintain all 85 R-O-Fs as a single large group, the Rather than maintain all 85 R-O-Fs as a single large group, the Rather than maintain all 85 R-O-Fs as a single large group, the Rather than maintain all 85 R-O-Fs as a single large group, the Rather than maintain all 85 R-O-Fs as a single large group, the Rather than maintain all 85 R-O-Fs as a single large group, the Rather than maintain all 85 R-O-Fs as a single large group, the Rather than maintain all 85 R-O-Fs as a single large group, the Diaz Team found arranging and presenting them in categories Diaz Team found arranging and presenting them in categories Diaz Team found arranging and presenting them in categories Diaz Team found arranging and presenting them in categories Diaz Team found arranging and presenting them in categories Diaz Team found arranging and presenting them in categories Diaz Team found arranging and presenting them in categories Diaz Team found arranging and presenting them in categories Diaz Team found arranging and presenting them in categories Diaz Team found arranging and presenting them in categories Diaz Team found arranging and presenting them in categories could utilize them most effectively. After extensive analysis of could utilize them most effectively. After extensive analysis of could utilize them most effectively. After extensive analysis of could utilize them most effectively. After extensive analysis of could utilize them most effectively. After extensive analysis of could utilize them most effectively. After extensive analysis of could utilize them most effectively. After extensive analysis of could utilize them most effectively. After extensive analysis of could utilize them most effectively. After extensive analysis of could utilize them most effectively. After extensive analysis of could utilize them most effectively. After extensive analysis of the NASA workforce inputs from Safety and Mission Success the NASA workforce inputs from Safety and Mission Success the NASA workforce inputs from Safety and Mission Success the NASA workforce inputs from Safety and Mission Success the NASA workforce inputs from Safety and Mission Success the NASA workforce inputs from Safety and Mission Success the NASA workforce inputs from Safety and Mission Success the NASA workforce inputs from Safety and Mission Success the NASA workforce inputs from Safety and Mission Success the NASA workforce inputs from Safety and Mission Success the NASA workforce inputs from Safety and Mission Success the NASA workforce inputs from Safety and Mission Success Week, the comments received were grouped into seven catego-Week, the comments received were grouped into seven catego-Week, the comments received were grouped into seven catego-Week, the comments received were grouped into seven catego-Week, the comments received were grouped into seven catego-Week, the comments received were grouped into seven catego-Week, the comments received were grouped into seven catego-Week, the comments received were grouped into seven catego-Week, the comments received were grouped into seven catego-Week, the comments received were grouped into seven catego-Week, the comments received were grouped into seven catego-ries:ries:

• LeadershipLeadershipLeadershipLeadership• LearningLearning• CommunicationCommunicationCommunicationCommunication• Processes & RulesProcesses & RulesProcesses & RulesProcesses & Rules• Technical CapabilitiesTechnical CapabilitiesTechnical CapabilitiesTechnical CapabilitiesTechnical Capabilities• Organizational StructureOrganizational StructureOrganizational StructureOrganizational StructureOrganizational StructureOrganizational Structure• Risk ManagementRisk ManagementRisk ManagementRisk Management

Each category is described in more detail throughout the Report, Each category is described in more detail throughout the Report, Each category is described in more detail throughout the Report, Each category is described in more detail throughout the Report, Each category is described in more detail throughout the Report, Each category is described in more detail throughout the Report, Each category is described in more detail throughout the Report, Each category is described in more detail throughout the Report, Each category is described in more detail throughout the Report, Each category is described in more detail throughout the Report, Each category is described in more detail throughout the Report, including the Diaz Teamʼs conclusions about the R-O-Fs in that including the Diaz Teamʼs conclusions about the R-O-Fs in that including the Diaz Teamʼs conclusions about the R-O-Fs in that including the Diaz Teamʼs conclusions about the R-O-Fs in that including the Diaz Teamʼs conclusions about the R-O-Fs in that including the Diaz Teamʼs conclusions about the R-O-Fs in that including the Diaz Teamʼs conclusions about the R-O-Fs in that including the Diaz Teamʼs conclusions about the R-O-Fs in that including the Diaz Teamʼs conclusions about the R-O-Fs in that including the Diaz Teamʼs conclusions about the R-O-Fs in that including the Diaz Teamʼs conclusions about the R-O-Fs in that including the Diaz Teamʼs conclusions about the R-O-Fs in that category. Each of the seven sections discussing the categories category. Each of the seven sections discussing the categories category. Each of the seven sections discussing the categories category. Each of the seven sections discussing the categories category. Each of the seven sections discussing the categories category. Each of the seven sections discussing the categories category. Each of the seven sections discussing the categories category. Each of the seven sections discussing the categories category. Each of the seven sections discussing the categories category. Each of the seven sections discussing the categories category. Each of the seven sections discussing the categories has a summary that follows the approach shown in Figure 5. has a summary that follows the approach shown in Figure 5. has a summary that follows the approach shown in Figure 5. has a summary that follows the approach shown in Figure 5. has a summary that follows the approach shown in Figure 5. has a summary that follows the approach shown in Figure 5. has a summary that follows the approach shown in Figure 5. has a summary that follows the approach shown in Figure 5. has a summary that follows the approach shown in Figure 5. has a summary that follows the approach shown in Figure 5.

Figure 4. Overlap currently exists between the Implementation Plans for different organizations. NASA Headquarters must coordinate when duplications of efforts might occur.

DiazTeamMatrix

Office of Space FlightSelf Assessment

+RTF Suggestions

Safety & MissionSuccess Week

+Continuing Dialogue

R-O-F

Broadly Applicable?Diaz Team Report

Returnto Flight

ImplementationPlan

Continuing FlightImplementation

Plan

Next-Generation Vehicle

ImplementationPlan(s)

Agency-WideRenewed Commitment

to ExcellenceImplementation Plan(s)

AircraftOperations

ImplementationPlan(s)

SpeSpecccccc mmmmmmmmmmmmcccccciiiiiiffffffiiiiiicccccc ttttttooooooooo PPPPPPrrrrrrooooooggggggrrrrrraaaaaaaaammmmmm AAAAAAAAAAAAAAAgggggggggeeeeeennnnnnccccccyyy WWWWWWWWWiiiiiiddddddeeeeee

ISS

CAIB

9

Figure 5. The Diaz Team categorized the CAIB R-O-Fs into seven distinct categories, each of which has a major premise. Each category is fully addressed in the body of the Report.

RENEWED COMMITMENTTO EXCELLENCE

IMPLEMENTATION PLAN(S)

RENEWED COMMITMENTTO EXCELLENCE

IMPLEMENTATION PLAN(S)

C ts

DIAZ TEAM FINAL REPORT

Diaz Team rmination

Diaz Team Matrix

Safety & Mission SuccessWeek Feedback

CAIB Statement

m Determ

CAIB Statemen

P e

C ts

m rm

C sntsents

Premise

CObservation

Diaz TeamCategory

Management practices are a causeof the accident

•

NASA has not followed its own rules•

NASA has not demonstrated thecharacteristics of a learning organization

•

NASA's in-house capabilities &expertise have eroded

•

Communication did not flow effectively•

NASA's safety & engineeringorganizations lack authority andindependence

•

NASA fails to account for programrisk

•

Leadership

Learning

Risk Management

Organizational Structure

Communications

Processes & Rules

Technical Capabilities

CAIBCCAIB

WHAT DIDTHE CAIBREPORT SAY?

1 01 0

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

Leadership – Diaz Team Goal

The Agency should assess whether program management and budget formulation processes are adequate to assure there is an appropriate balance of requirements, resources, and risk to ensure safety and mission success.

CAIB Report Chapter 8, p203:Leaders create culture. It is their responsibility to change it. Top administrators must take responsibility for risk, failure, and safety by remaining alert to the effects their decisions have on the system. Leaders are responsible for establishing the conditions that lead to their subordinates’ successes or failures.

1.2 LEADERSHIP

Management practices are a cause of the accident.

Agency-wide Themes• Leaders must lead by example, creating conditions

and a culture for safety and mission success.• Leaders must balance schedule and risk.• Leaders should allow and encourage diversity of

views, eliminate retribution towards those with differing opinions, and understand that ”No” is an acceptable answer.

• Leaders should be grown throughout all levels of the organization, through succession planning and developmental experiences.

NASA has a strong heritage for developing leaders at all levels NASA has a strong heritage for developing leaders at all levels NASA has a strong heritage for developing leaders at all levels NASA has a strong heritage for developing leaders at all levels NASA has a strong heritage for developing leaders at all levels NASA has a strong heritage for developing leaders at all levels NASA has a strong heritage for developing leaders at all levels NASA has a strong heritage for developing leaders at all levels NASA has a strong heritage for developing leaders at all levels NASA has a strong heritage for developing leaders at all levels NASA has a strong heritage for developing leaders at all levels NASA has a strong heritage for developing leaders at all levels of the Agency who have a “can-do” attitude. They have brought of the Agency who have a “can-do” attitude. They have brought of the Agency who have a “can-do” attitude. They have brought of the Agency who have a “can-do” attitude. They have brought of the Agency who have a “can-do” attitude. They have brought of the Agency who have a “can-do” attitude. They have brought of the Agency who have a “can-do” attitude. They have brought of the Agency who have a “can-do” attitude. They have brought of the Agency who have a “can-do” attitude. They have brought of the Agency who have a “can-do” attitude. They have brought of the Agency who have a “can-do” attitude. They have brought of the Agency who have a “can-do” attitude. They have brought our Nation to the Moon and back, launched and managed hun-our Nation to the Moon and back, launched and managed hun-our Nation to the Moon and back, launched and managed hun-our Nation to the Moon and back, launched and managed hun-our Nation to the Moon and back, launched and managed hun-our Nation to the Moon and back, launched and managed hun-our Nation to the Moon and back, launched and managed hun-our Nation to the Moon and back, launched and managed hun-our Nation to the Moon and back, launched and managed hun-our Nation to the Moon and back, launched and managed hun-our Nation to the Moon and back, launched and managed hun-our Nation to the Moon and back, launched and managed hun-dreds of safe and successful human and unmanned missions to dreds of safe and successful human and unmanned missions to dreds of safe and successful human and unmanned missions to dreds of safe and successful human and unmanned missions to dreds of safe and successful human and unmanned missions to dreds of safe and successful human and unmanned missions to dreds of safe and successful human and unmanned missions to dreds of safe and successful human and unmanned missions to dreds of safe and successful human and unmanned missions to dreds of safe and successful human and unmanned missions to dreds of safe and successful human and unmanned missions to dreds of safe and successful human and unmanned missions to space, led us through seemingly hopeless situations like Apollo space, led us through seemingly hopeless situations like Apollo space, led us through seemingly hopeless situations like Apollo space, led us through seemingly hopeless situations like Apollo space, led us through seemingly hopeless situations like Apollo space, led us through seemingly hopeless situations like Apollo space, led us through seemingly hopeless situations like Apollo space, led us through seemingly hopeless situations like Apollo space, led us through seemingly hopeless situations like Apollo space, led us through seemingly hopeless situations like Apollo space, led us through seemingly hopeless situations like Apollo space, led us through seemingly hopeless situations like Apollo space, led us through seemingly hopeless situations like Apollo 13, and begun the complex construction and operation of the In-13, and begun the complex construction and operation of the In-13, and begun the complex construction and operation of the In-13, and begun the complex construction and operation of the In-13, and begun the complex construction and operation of the In-13, and begun the complex construction and operation of the In-13, and begun the complex construction and operation of the In-13, and begun the complex construction and operation of the In-13, and begun the complex construction and operation of the In-13, and begun the complex construction and operation of the In-13, and begun the complex construction and operation of the In-13, and begun the complex construction and operation of the In-ternational Space Station. However, with the seriousness of the ternational Space Station. However, with the seriousness of the ternational Space Station. However, with the seriousness of the ternational Space Station. However, with the seriousness of the ternational Space Station. However, with the seriousness of the ternational Space Station. However, with the seriousness of the ternational Space Station. However, with the seriousness of the ternational Space Station. However, with the seriousness of the ternational Space Station. However, with the seriousness of the ternational Space Station. However, with the seriousness of the ternational Space Station. However, with the seriousness of the ternational Space Station. However, with the seriousness of the ternational Space Station. However, with the seriousness of the ColumbiaColumbiaColumbia accident and the CAIB Report, NASA leaders need to accident and the CAIB Report, NASA leaders need to accident and the CAIB Report, NASA leaders need to accident and the CAIB Report, NASA leaders need to accident and the CAIB Report, NASA leaders need to accident and the CAIB Report, NASA leaders need to accident and the CAIB Report, NASA leaders need to accident and the CAIB Report, NASA leaders need to accident and the CAIB Report, NASA leaders need to accident and the CAIB Report, NASA leaders need to refl ect upon and grow from the lessons learned. refl ect upon and grow from the lessons learned. refl ect upon and grow from the lessons learned. refl ect upon and grow from the lessons learned. refl ect upon and grow from the lessons learned. refl ect upon and grow from the lessons learned. refl ect upon and grow from the lessons learned. refl ect upon and grow from the lessons learned. refl ect upon and grow from the lessons learned. refl ect upon and grow from the lessons learned.

The CAIB Report had this to say about NASA̓ s Leadership:The CAIB Report had this to say about NASA̓ s Leadership:The CAIB Report had this to say about NASA̓ s Leadership:The CAIB Report had this to say about NASA̓ s Leadership:The CAIB Report had this to say about NASA̓ s Leadership:The CAIB Report had this to say about NASA̓ s Leadership:The CAIB Report had this to say about NASA̓ s Leadership:The CAIB Report had this to say about NASA̓ s Leadership:The CAIB Report had this to say about NASA̓ s Leadership:The CAIB Report had this to say about NASA̓ s Leadership:The CAIB Report had this to say about NASA̓ s Leadership:

Post-ChallengerChallengerChallenger policy decisions made by the White policy decisions made by the White policy decisions made by the White policy decisions made by the White policy decisions made by the White policy decisions made by the White policy decisions made by the White policy decisions made by the White Challenger policy decisions made by the White ChallengerHouse, Congress, and NASA leadership resulted in the House, Congress, and NASA leadership resulted in the House, Congress, and NASA leadership resulted in the House, Congress, and NASA leadership resulted in the House, Congress, and NASA leadership resulted in the House, Congress, and NASA leadership resulted in the House, Congress, and NASA leadership resulted in the House, Congress, and NASA leadership resulted in the House, Congress, and NASA leadership resulted in the House, Congress, and NASA leadership resulted in the House, Congress, and NASA leadership resulted in the Agency reproducing many of the failings identifi ed by Agency reproducing many of the failings identifi ed by Agency reproducing many of the failings identifi ed by Agency reproducing many of the failings identifi ed by Agency reproducing many of the failings identifi ed by Agency reproducing many of the failings identifi ed by Agency reproducing many of the failings identifi ed by Agency reproducing many of the failings identifi ed by Agency reproducing many of the failings identifi ed by Agency reproducing many of the failings identifi ed by the Rogers Commission. Policy constraints affected the the Rogers Commission. Policy constraints affected the the Rogers Commission. Policy constraints affected the the Rogers Commission. Policy constraints affected the the Rogers Commission. Policy constraints affected the the Rogers Commission. Policy constraints affected the the Rogers Commission. Policy constraints affected the the Rogers Commission. Policy constraints affected the the Rogers Commission. Policy constraints affected the the Rogers Commission. Policy constraints affected the the Rogers Commission. Policy constraints affected the Shuttle Program’s organization culture, its structure, and Shuttle Program’s organization culture, its structure, and Shuttle Program’s organization culture, its structure, and Shuttle Program’s organization culture, its structure, and Shuttle Program’s organization culture, its structure, and Shuttle Program’s organization culture, its structure, and Shuttle Program’s organization culture, its structure, and Shuttle Program’s organization culture, its structure, and Shuttle Program’s organization culture, its structure, and Shuttle Program’s organization culture, its structure, and the structure of the safety system. The three combined to the structure of the safety system. The three combined to the structure of the safety system. The three combined to the structure of the safety system. The three combined to the structure of the safety system. The three combined to the structure of the safety system. The three combined to the structure of the safety system. The three combined to the structure of the safety system. The three combined to the structure of the safety system. The three combined to the structure of the safety system. The three combined to the structure of the safety system. The three combined to keep NASA on its slippery slope toward keep NASA on its slippery slope toward keep NASA on its slippery slope toward keep NASA on its slippery slope toward keep NASA on its slippery slope toward keep NASA on its slippery slope toward keep NASA on its slippery slope toward Challenger Challenger and ColumbiaColumbia. (CAIB Report, Chapter 8, p. 197). (CAIB Report, Chapter 8, p. 197). (CAIB Report, Chapter 8, p. 197). (CAIB Report, Chapter 8, p. 197). (CAIB Report, Chapter 8, p. 197). (CAIB Report, Chapter 8, p. 197). (CAIB Report, Chapter 8, p. 197)

The Diaz Teamʼs actions contained in the Diaz Team Matrix The Diaz Teamʼs actions contained in the Diaz Team Matrix The Diaz Teamʼs actions contained in the Diaz Team Matrix The Diaz Teamʼs actions contained in the Diaz Team Matrix The Diaz Teamʼs actions contained in the Diaz Team Matrix The Diaz Teamʼs actions contained in the Diaz Team Matrix The Diaz Teamʼs actions contained in the Diaz Team Matrix The Diaz Teamʼs actions contained in the Diaz Team Matrix The Diaz Teamʼs actions contained in the Diaz Team Matrix The Diaz Teamʼs actions contained in the Diaz Team Matrix The Diaz Teamʼs actions contained in the Diaz Team Matrix The Diaz Teamʼs actions contained in the Diaz Team Matrix require that everyone understand their responsibilities and are require that everyone understand their responsibilities and are require that everyone understand their responsibilities and are require that everyone understand their responsibilities and are require that everyone understand their responsibilities and are require that everyone understand their responsibilities and are require that everyone understand their responsibilities and are require that everyone understand their responsibilities and are require that everyone understand their responsibilities and are require that everyone understand their responsibilities and are require that everyone understand their responsibilities and are require that everyone understand their responsibilities and are require that everyone understand their responsibilities and are given the authority to perform their jobs, with the accountabil-given the authority to perform their jobs, with the accountabil-given the authority to perform their jobs, with the accountabil-given the authority to perform their jobs, with the accountabil-given the authority to perform their jobs, with the accountabil-given the authority to perform their jobs, with the accountabil-given the authority to perform their jobs, with the accountabil-given the authority to perform their jobs, with the accountabil-given the authority to perform their jobs, with the accountabil-given the authority to perform their jobs, with the accountabil-given the authority to perform their jobs, with the accountabil-given the authority to perform their jobs, with the accountabil-ity for their individual and programʼs successes and failures, ity for their individual and programʼs successes and failures, ity for their individual and programʼs successes and failures, ity for their individual and programʼs successes and failures, ity for their individual and programʼs successes and failures, ity for their individual and programʼs successes and failures, ity for their individual and programʼs successes and failures, ity for their individual and programʼs successes and failures, ity for their individual and programʼs successes and failures, ity for their individual and programʼs successes and failures, ity for their individual and programʼs successes and failures, ity for their individual and programʼs successes and failures, ity for their individual and programʼs successes and failures, including lessons learned. Leadership means making informed including lessons learned. Leadership means making informed including lessons learned. Leadership means making informed including lessons learned. Leadership means making informed including lessons learned. Leadership means making informed including lessons learned. Leadership means making informed including lessons learned. Leadership means making informed including lessons learned. Leadership means making informed including lessons learned. Leadership means making informed including lessons learned. Leadership means making informed including lessons learned. Leadership means making informed including lessons learned. Leadership means making informed decisions and treating staff and contractor support with respect decisions and treating staff and contractor support with respect decisions and treating staff and contractor support with respect decisions and treating staff and contractor support with respect decisions and treating staff and contractor support with respect decisions and treating staff and contractor support with respect decisions and treating staff and contractor support with respect decisions and treating staff and contractor support with respect decisions and treating staff and contractor support with respect decisions and treating staff and contractor support with respect decisions and treating staff and contractor support with respect decisions and treating staff and contractor support with respect and courtesy to ensure that everyone understands their inputs are and courtesy to ensure that everyone understands their inputs are and courtesy to ensure that everyone understands their inputs are and courtesy to ensure that everyone understands their inputs are and courtesy to ensure that everyone understands their inputs are and courtesy to ensure that everyone understands their inputs are and courtesy to ensure that everyone understands their inputs are and courtesy to ensure that everyone understands their inputs are and courtesy to ensure that everyone understands their inputs are and courtesy to ensure that everyone understands their inputs are and courtesy to ensure that everyone understands their inputs are and courtesy to ensure that everyone understands their inputs are valued and important. It also involves empowering and develop-valued and important. It also involves empowering and develop-valued and important. It also involves empowering and develop-valued and important. It also involves empowering and develop-valued and important. It also involves empowering and develop-valued and important. It also involves empowering and develop-valued and important. It also involves empowering and develop-valued and important. It also involves empowering and develop-valued and important. It also involves empowering and develop-valued and important. It also involves empowering and develop-valued and important. It also involves empowering and develop-valued and important. It also involves empowering and develop-ing the workforce, listening and communicating with them more ing the workforce, listening and communicating with them more ing the workforce, listening and communicating with them more ing the workforce, listening and communicating with them more ing the workforce, listening and communicating with them more ing the workforce, listening and communicating with them more ing the workforce, listening and communicating with them more ing the workforce, listening and communicating with them more ing the workforce, listening and communicating with them more ing the workforce, listening and communicating with them more ing the workforce, listening and communicating with them more ing the workforce, listening and communicating with them more ing the workforce, listening and communicating with them more effectively, and developing future leaders through progressive effectively, and developing future leaders through progressive effectively, and developing future leaders through progressive effectively, and developing future leaders through progressive effectively, and developing future leaders through progressive effectively, and developing future leaders through progressive effectively, and developing future leaders through progressive effectively, and developing future leaders through progressive effectively, and developing future leaders through progressive effectively, and developing future leaders through progressive effectively, and developing future leaders through progressive effectively, and developing future leaders through progressive leadership development and effective organization succession leadership development and effective organization succession leadership development and effective organization succession leadership development and effective organization succession leadership development and effective organization succession leadership development and effective organization succession leadership development and effective organization succession leadership development and effective organization succession leadership development and effective organization succession leadership development and effective organization succession leadership development and effective organization succession leadership development and effective organization succession leadership development and effective organization succession

planning and practices. Leadership means creating a climate and planning and practices. Leadership means creating a climate and planning and practices. Leadership means creating a climate and planning and practices. Leadership means creating a climate and planning and practices. Leadership means creating a climate and planning and practices. Leadership means creating a climate and planning and practices. Leadership means creating a climate and planning and practices. Leadership means creating a climate and planning and practices. Leadership means creating a climate and planning and practices. Leadership means creating a climate and planning and practices. Leadership means creating a climate and conditions for NASA employees and organizations to achieve conditions for NASA employees and organizations to achieve conditions for NASA employees and organizations to achieve conditions for NASA employees and organizations to achieve conditions for NASA employees and organizations to achieve conditions for NASA employees and organizations to achieve conditions for NASA employees and organizations to achieve conditions for NASA employees and organizations to achieve conditions for NASA employees and organizations to achieve conditions for NASA employees and organizations to achieve conditions for NASA employees and organizations to achieve conditions for NASA employees and organizations to achieve safety and mission success.safety and mission success.safety and mission success.safety and mission success.safety and mission success.

The criteria used to delineate those R-O-Fs that were applied to The criteria used to delineate those R-O-Fs that were applied to The criteria used to delineate those R-O-Fs that were applied to The criteria used to delineate those R-O-Fs that were applied to The criteria used to delineate those R-O-Fs that were applied to The criteria used to delineate those R-O-Fs that were applied to The criteria used to delineate those R-O-Fs that were applied to The criteria used to delineate those R-O-Fs that were applied to The criteria used to delineate those R-O-Fs that were applied to The criteria used to delineate those R-O-Fs that were applied to The criteria used to delineate those R-O-Fs that were applied to leadership included the Agency-wide themes and a leaderʼs abil-leadership included the Agency-wide themes and a leaderʼs abil-leadership included the Agency-wide themes and a leaderʼs abil-leadership included the Agency-wide themes and a leaderʼs abil-leadership included the Agency-wide themes and a leaderʼs abil-leadership included the Agency-wide themes and a leaderʼs abil-leadership included the Agency-wide themes and a leaderʼs abil-leadership included the Agency-wide themes and a leaderʼs abil-leadership included the Agency-wide themes and a leaderʼs abil-leadership included the Agency-wide themes and a leaderʼs abil-leadership included the Agency-wide themes and a leaderʼs abil-leadership included the Agency-wide themes and a leaderʼs abil-ity to make and support decisions. These criteria address:ity to make and support decisions. These criteria address:ity to make and support decisions. These criteria address:ity to make and support decisions. These criteria address:ity to make and support decisions. These criteria address:ity to make and support decisions. These criteria address:ity to make and support decisions. These criteria address:ity to make and support decisions. These criteria address:ity to make and support decisions. These criteria address:ity to make and support decisions. These criteria address:

• Empowerment by understanding and communicating Empowerment by understanding and communicating Empowerment by understanding and communicating Empowerment by understanding and communicating Empowerment by understanding and communicating Empowerment by understanding and communicating Empowerment by understanding and communicating Empowerment by understanding and communicating Empowerment by understanding and communicating responsibility, accountability, and authority.responsibility, accountability, and authority.responsibility, accountability, and authority.responsibility, accountability, and authority.responsibility, accountability, and authority.responsibility, accountability, and authority.responsibility, accountability, and authority.responsibility, accountability, and authority.

• Serving as an example and role model to employees Serving as an example and role model to employees Serving as an example and role model to employees Serving as an example and role model to employees Serving as an example and role model to employees Serving as an example and role model to employees Serving as an example and role model to employees Serving as an example and role model to employees Serving as an example and role model to employees Serving as an example and role model to employees by understanding and following the rules (but not by understanding and following the rules (but not by understanding and following the rules (but not by understanding and following the rules (but not by understanding and following the rules (but not by understanding and following the rules (but not by understanding and following the rules (but not by understanding and following the rules (but not by understanding and following the rules (but not “blindly”), and having a willingness to challenge the “blindly”), and having a willingness to challenge the “blindly”), and having a willingness to challenge the “blindly”), and having a willingness to challenge the “blindly”), and having a willingness to challenge the “blindly”), and having a willingness to challenge the “blindly”), and having a willingness to challenge the “blindly”), and having a willingness to challenge the “blindly”), and having a willingness to challenge the “blindly”), and having a willingness to challenge the rules when safety and mission success are at stake.rules when safety and mission success are at stake.rules when safety and mission success are at stake.rules when safety and mission success are at stake.rules when safety and mission success are at stake.rules when safety and mission success are at stake.rules when safety and mission success are at stake.rules when safety and mission success are at stake.rules when safety and mission success are at stake.

• A willingness and ability to challenge schedules when A willingness and ability to challenge schedules when A willingness and ability to challenge schedules when A willingness and ability to challenge schedules when A willingness and ability to challenge schedules when A willingness and ability to challenge schedules when A willingness and ability to challenge schedules when A willingness and ability to challenge schedules when A willingness and ability to challenge schedules when A willingness and ability to challenge schedules when A willingness and ability to challenge schedules when appropriate and necessary based upon well thought-out appropriate and necessary based upon well thought-out appropriate and necessary based upon well thought-out appropriate and necessary based upon well thought-out appropriate and necessary based upon well thought-out appropriate and necessary based upon well thought-out appropriate and necessary based upon well thought-out appropriate and necessary based upon well thought-out appropriate and necessary based upon well thought-out appropriate and necessary based upon well thought-out and presented analyses of risks.and presented analyses of risks.and presented analyses of risks.and presented analyses of risks.and presented analyses of risks.and presented analyses of risks.

• Respect of others and fostering fair consideration of all Respect of others and fostering fair consideration of all Respect of others and fostering fair consideration of all Respect of others and fostering fair consideration of all Respect of others and fostering fair consideration of all Respect of others and fostering fair consideration of all Respect of others and fostering fair consideration of all Respect of others and fostering fair consideration of all Respect of others and fostering fair consideration of all Respect of others and fostering fair consideration of all points of view.points of view.points of view.

The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced the Diaz Team assessments.the Diaz Team assessments.the Diaz Team assessments.the Diaz Team assessments.the Diaz Team assessments.the Diaz Team assessments.

» We need to make sure every voice is heard without We need to make sure every voice is heard without We need to make sure every voice is heard without We need to make sure every voice is heard without We need to make sure every voice is heard without We need to make sure every voice is heard without We need to make sure every voice is heard without We need to make sure every voice is heard without We need to make sure every voice is heard without We need to make sure every voice is heard without fear of retaliation or suppression.fear of retaliation or suppression.fear of retaliation or suppression.fear of retaliation or suppression.fear of retaliation or suppression.fear of retaliation or suppression.

» NASA leadership has become preoccupied by actions NASA leadership has become preoccupied by actions NASA leadership has become preoccupied by actions NASA leadership has become preoccupied by actions NASA leadership has become preoccupied by actions NASA leadership has become preoccupied by actions NASA leadership has become preoccupied by actions NASA leadership has become preoccupied by actions NASA leadership has become preoccupied by actions NASA leadership has become preoccupied by actions to address symptoms; we need the resources and lead-to address symptoms; we need the resources and lead-to address symptoms; we need the resources and lead-to address symptoms; we need the resources and lead-to address symptoms; we need the resources and lead-to address symptoms; we need the resources and lead-to address symptoms; we need the resources and lead-to address symptoms; we need the resources and lead-to address symptoms; we need the resources and lead-to address symptoms; we need the resources and lead-to address symptoms; we need the resources and lead-ership commitment to fi x underlying causes.ership commitment to fi x underlying causes.ership commitment to fi x underlying causes.ership commitment to fi x underlying causes.ership commitment to fi x underlying causes.ership commitment to fi x underlying causes.ership commitment to fi x underlying causes.ership commitment to fi x underlying causes.

»» We need to stress among NASA leadership the impor-We need to stress among NASA leadership the impor-We need to stress among NASA leadership the impor-We need to stress among NASA leadership the impor-We need to stress among NASA leadership the impor-We need to stress among NASA leadership the impor-We need to stress among NASA leadership the impor-We need to stress among NASA leadership the impor-We need to stress among NASA leadership the impor-We need to stress among NASA leadership the impor-We need to stress among NASA leadership the impor-tance of responding to even the lowest level question. tance of responding to even the lowest level question. tance of responding to even the lowest level question. tance of responding to even the lowest level question. tance of responding to even the lowest level question. tance of responding to even the lowest level question. tance of responding to even the lowest level question. tance of responding to even the lowest level question. tance of responding to even the lowest level question. tance of responding to even the lowest level question. This was exactly why NASA did not exercise addition-This was exactly why NASA did not exercise addition-This was exactly why NASA did not exercise addition-This was exactly why NASA did not exercise addition-This was exactly why NASA did not exercise addition-This was exactly why NASA did not exercise addition-This was exactly why NASA did not exercise addition-This was exactly why NASA did not exercise addition-This was exactly why NASA did not exercise addition-This was exactly why NASA did not exercise addition-This was exactly why NASA did not exercise addition-al techniques with al techniques with al techniques with al techniques with Columbia Columbia Columbia to research the problem.to research the problem.to research the problem.to research the problem.

Every member of the workforce must know his or her position Every member of the workforce must know his or her position Every member of the workforce must know his or her position Every member of the workforce must know his or her position Every member of the workforce must know his or her position Every member of the workforce must know his or her position Every member of the workforce must know his or her position Every member of the workforce must know his or her position Every member of the workforce must know his or her position Every member of the workforce must know his or her position Every member of the workforce must know his or her position in the organization; all must know their authority, responsibility, in the organization; all must know their authority, responsibility, in the organization; all must know their authority, responsibility, in the organization; all must know their authority, responsibility, in the organization; all must know their authority, responsibility, in the organization; all must know their authority, responsibility, in the organization; all must know their authority, responsibility, in the organization; all must know their authority, responsibility, in the organization; all must know their authority, responsibility, in the organization; all must know their authority, responsibility, in the organization; all must know their authority, responsibility, and accountability. The Diaz Team came to believe that at the and accountability. The Diaz Team came to believe that at the and accountability. The Diaz Team came to believe that at the and accountability. The Diaz Team came to believe that at the and accountability. The Diaz Team came to believe that at the and accountability. The Diaz Team came to believe that at the and accountability. The Diaz Team came to believe that at the and accountability. The Diaz Team came to believe that at the and accountability. The Diaz Team came to believe that at the and accountability. The Diaz Team came to believe that at the and accountability. The Diaz Team came to believe that at the and accountability. The Diaz Team came to believe that at the root of some of the CAIB observations and individual comments root of some of the CAIB observations and individual comments root of some of the CAIB observations and individual comments root of some of the CAIB observations and individual comments root of some of the CAIB observations and individual comments root of some of the CAIB observations and individual comments root of some of the CAIB observations and individual comments root of some of the CAIB observations and individual comments root of some of the CAIB observations and individual comments root of some of the CAIB observations and individual comments root of some of the CAIB observations and individual comments was a concern about leadershipʼs ability to determine whether was a concern about leadershipʼs ability to determine whether was a concern about leadershipʼs ability to determine whether was a concern about leadershipʼs ability to determine whether was a concern about leadershipʼs ability to determine whether was a concern about leadershipʼs ability to determine whether was a concern about leadershipʼs ability to determine whether was a concern about leadershipʼs ability to determine whether was a concern about leadershipʼs ability to determine whether was a concern about leadershipʼs ability to determine whether was a concern about leadershipʼs ability to determine whether was a concern about leadershipʼs ability to determine whether there was an appropriate balance between requirements and there was an appropriate balance between requirements and there was an appropriate balance between requirements and there was an appropriate balance between requirements and there was an appropriate balance between requirements and there was an appropriate balance between requirements and there was an appropriate balance between requirements and there was an appropriate balance between requirements and there was an appropriate balance between requirements and there was an appropriate balance between requirements and there was an appropriate balance between requirements and resources allocated to their achievement. The Diaz Team goal resources allocated to their achievement. The Diaz Team goal resources allocated to their achievement. The Diaz Team goal resources allocated to their achievement. The Diaz Team goal resources allocated to their achievement. The Diaz Team goal resources allocated to their achievement. The Diaz Team goal resources allocated to their achievement. The Diaz Team goal resources allocated to their achievement. The Diaz Team goal resources allocated to their achievement. The Diaz Team goal resources allocated to their achievement. The Diaz Team goal resources allocated to their achievement. The Diaz Team goal resources allocated to their achievement. The Diaz Team goal on Leadership was developed in response to that concern. For on Leadership was developed in response to that concern. For on Leadership was developed in response to that concern. For on Leadership was developed in response to that concern. For on Leadership was developed in response to that concern. For on Leadership was developed in response to that concern. For on Leadership was developed in response to that concern. For on Leadership was developed in response to that concern. For on Leadership was developed in response to that concern. For on Leadership was developed in response to that concern. For on Leadership was developed in response to that concern. For this goal to succeed, changes discussed in other sections of the this goal to succeed, changes discussed in other sections of the this goal to succeed, changes discussed in other sections of the this goal to succeed, changes discussed in other sections of the this goal to succeed, changes discussed in other sections of the this goal to succeed, changes discussed in other sections of the this goal to succeed, changes discussed in other sections of the this goal to succeed, changes discussed in other sections of the this goal to succeed, changes discussed in other sections of the this goal to succeed, changes discussed in other sections of the this goal to succeed, changes discussed in other sections of the Report must also be pursued.Report must also be pursued.Report must also be pursued.Report must also be pursued.Report must also be pursued.

In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address each R-O-F, the Diaz Team has one goal addressing the Leader-each R-O-F, the Diaz Team has one goal addressing the Leader-each R-O-F, the Diaz Team has one goal addressing the Leader-each R-O-F, the Diaz Team has one goal addressing the Leader-each R-O-F, the Diaz Team has one goal addressing the Leader-each R-O-F, the Diaz Team has one goal addressing the Leader-each R-O-F, the Diaz Team has one goal addressing the Leader-each R-O-F, the Diaz Team has one goal addressing the Leader-each R-O-F, the Diaz Team has one goal addressing the Leader-each R-O-F, the Diaz Team has one goal addressing the Leader-each R-O-F, the Diaz Team has one goal addressing the Leader-ship category, as shown in Table 2.ship category, as shown in Table 2.ship category, as shown in Table 2.ship category, as shown in Table 2.ship category, as shown in Table 2.ship category, as shown in Table 2.ship category, as shown in Table 2.

1 11 1

1.3 LEARNING

CAIB Report Chapter 7, p192:The Board concludes that NASA’s current organization does not provide effective checks-and-balances, does not have an independent safety program, and has not demonstrated the characteristics of a learning organization.

NASA has not demonstrated the characteristics of a learning organization.

Agency-wide Themes• NASA should provide robust simulation and emer-

gency response training.• Tools, databases, and models should be developed

and used appropriately.

Much was said in the CAIB Report about the NASA culture and Much was said in the CAIB Report about the NASA culture and Much was said in the CAIB Report about the NASA culture and Much was said in the CAIB Report about the NASA culture and Much was said in the CAIB Report about the NASA culture and Much was said in the CAIB Report about the NASA culture and Much was said in the CAIB Report about the NASA culture and Much was said in the CAIB Report about the NASA culture and Much was said in the CAIB Report about the NASA culture and Much was said in the CAIB Report about the NASA culture and Much was said in the CAIB Report about the NASA culture and Much was said in the CAIB Report about the NASA culture and Much was said in the CAIB Report about the NASA culture and how its attributes contributed to the how its attributes contributed to the how its attributes contributed to the how its attributes contributed to the how its attributes contributed to the how its attributes contributed to the how its attributes contributed to the ColumbiaColumbia accident. The accident. The accident. The accident. The CAIB concluded NASA “has not demonstrated the characteris-CAIB concluded NASA “has not demonstrated the characteris-CAIB concluded NASA “has not demonstrated the characteris-CAIB concluded NASA “has not demonstrated the characteris-CAIB concluded NASA “has not demonstrated the characteris-CAIB concluded NASA “has not demonstrated the characteris-CAIB concluded NASA “has not demonstrated the characteris-CAIB concluded NASA “has not demonstrated the characteris-CAIB concluded NASA “has not demonstrated the characteris-CAIB concluded NASA “has not demonstrated the characteris-CAIB concluded NASA “has not demonstrated the characteris-CAIB concluded NASA “has not demonstrated the characteris-CAIB concluded NASA “has not demonstrated the characteris-tics of a learning organization” after investigators observed mis-tics of a learning organization” after investigators observed mis-tics of a learning organization” after investigators observed mis-tics of a learning organization” after investigators observed mis-tics of a learning organization” after investigators observed mis-tics of a learning organization” after investigators observed mis-tics of a learning organization” after investigators observed mis-tics of a learning organization” after investigators observed mis-tics of a learning organization” after investigators observed mis-tics of a learning organization” after investigators observed mis-tics of a learning organization” after investigators observed mis-tics of a learning organization” after investigators observed mis-takes being repeated and lessons from the past apparently being takes being repeated and lessons from the past apparently being takes being repeated and lessons from the past apparently being takes being repeated and lessons from the past apparently being takes being repeated and lessons from the past apparently being takes being repeated and lessons from the past apparently being takes being repeated and lessons from the past apparently being takes being repeated and lessons from the past apparently being takes being repeated and lessons from the past apparently being takes being repeated and lessons from the past apparently being takes being repeated and lessons from the past apparently being takes being repeated and lessons from the past apparently being takes being repeated and lessons from the past apparently being relearned. The CAIB provided NASA with a number of recom-relearned. The CAIB provided NASA with a number of recom-relearned. The CAIB provided NASA with a number of recom-relearned. The CAIB provided NASA with a number of recom-relearned. The CAIB provided NASA with a number of recom-relearned. The CAIB provided NASA with a number of recom-relearned. The CAIB provided NASA with a number of recom-relearned. The CAIB provided NASA with a number of recom-relearned. The CAIB provided NASA with a number of recom-relearned. The CAIB provided NASA with a number of recom-relearned. The CAIB provided NASA with a number of recom-relearned. The CAIB provided NASA with a number of recom-mendations and fi ndings that could help it achieve the benefi cial mendations and fi ndings that could help it achieve the benefi cial mendations and fi ndings that could help it achieve the benefi cial mendations and fi ndings that could help it achieve the benefi cial mendations and fi ndings that could help it achieve the benefi cial mendations and fi ndings that could help it achieve the benefi cial mendations and fi ndings that could help it achieve the benefi cial mendations and fi ndings that could help it achieve the benefi cial mendations and fi ndings that could help it achieve the benefi cial mendations and fi ndings that could help it achieve the benefi cial mendations and fi ndings that could help it achieve the benefi cial mendations and fi ndings that could help it achieve the benefi cial traits of a learning organization.traits of a learning organization.traits of a learning organization.traits of a learning organization.traits of a learning organization.traits of a learning organization.

It is recognized there are efforts underway in NASA to address It is recognized there are efforts underway in NASA to address It is recognized there are efforts underway in NASA to address It is recognized there are efforts underway in NASA to address It is recognized there are efforts underway in NASA to address It is recognized there are efforts underway in NASA to address It is recognized there are efforts underway in NASA to address It is recognized there are efforts underway in NASA to address It is recognized there are efforts underway in NASA to address It is recognized there are efforts underway in NASA to address It is recognized there are efforts underway in NASA to address It is recognized there are efforts underway in NASA to address It is recognized there are efforts underway in NASA to address knowledge capture, management, and dissemination. These ac-knowledge capture, management, and dissemination. These ac-knowledge capture, management, and dissemination. These ac-knowledge capture, management, and dissemination. These ac-knowledge capture, management, and dissemination. These ac-knowledge capture, management, and dissemination. These ac-knowledge capture, management, and dissemination. These ac-knowledge capture, management, and dissemination. These ac-knowledge capture, management, and dissemination. These ac-knowledge capture, management, and dissemination. These ac-knowledge capture, management, and dissemination. These ac-knowledge capture, management, and dissemination. These ac-tions are in response to the concern for the impending retirement tions are in response to the concern for the impending retirement tions are in response to the concern for the impending retirement tions are in response to the concern for the impending retirement tions are in response to the concern for the impending retirement tions are in response to the concern for the impending retirement tions are in response to the concern for the impending retirement tions are in response to the concern for the impending retirement tions are in response to the concern for the impending retirement tions are in response to the concern for the impending retirement tions are in response to the concern for the impending retirement tions are in response to the concern for the impending retirement tions are in response to the concern for the impending retirement of a large segment of the NASA workforce. But more needs to of a large segment of the NASA workforce. But more needs to of a large segment of the NASA workforce. But more needs to of a large segment of the NASA workforce. But more needs to of a large segment of the NASA workforce. But more needs to of a large segment of the NASA workforce. But more needs to of a large segment of the NASA workforce. But more needs to of a large segment of the NASA workforce. But more needs to of a large segment of the NASA workforce. But more needs to of a large segment of the NASA workforce. But more needs to of a large segment of the NASA workforce. But more needs to of a large segment of the NASA workforce. But more needs to be done to understand what the knowledge architecture in NASA be done to understand what the knowledge architecture in NASA be done to understand what the knowledge architecture in NASA be done to understand what the knowledge architecture in NASA be done to understand what the knowledge architecture in NASA be done to understand what the knowledge architecture in NASA be done to understand what the knowledge architecture in NASA be done to understand what the knowledge architecture in NASA be done to understand what the knowledge architecture in NASA be done to understand what the knowledge architecture in NASA be done to understand what the knowledge architecture in NASA be done to understand what the knowledge architecture in NASA be done to understand what the knowledge architecture in NASA is so that steps can be taken to preserve it. NASA needs a robust is so that steps can be taken to preserve it. NASA needs a robust is so that steps can be taken to preserve it. NASA needs a robust is so that steps can be taken to preserve it. NASA needs a robust is so that steps can be taken to preserve it. NASA needs a robust is so that steps can be taken to preserve it. NASA needs a robust is so that steps can be taken to preserve it. NASA needs a robust is so that steps can be taken to preserve it. NASA needs a robust is so that steps can be taken to preserve it. NASA needs a robust is so that steps can be taken to preserve it. NASA needs a robust is so that steps can be taken to preserve it. NASA needs a robust is so that steps can be taken to preserve it. NASA needs a robust infrastructure to support all aspects of decision-making and infrastructure to support all aspects of decision-making and infrastructure to support all aspects of decision-making and infrastructure to support all aspects of decision-making and infrastructure to support all aspects of decision-making and infrastructure to support all aspects of decision-making and infrastructure to support all aspects of decision-making and infrastructure to support all aspects of decision-making and infrastructure to support all aspects of decision-making and infrastructure to support all aspects of decision-making and infrastructure to support all aspects of decision-making and infrastructure to support all aspects of decision-making and knowledge management. The CAIB Report said that NASA has knowledge management. The CAIB Report said that NASA has knowledge management. The CAIB Report said that NASA has knowledge management. The CAIB Report said that NASA has knowledge management. The CAIB Report said that NASA has knowledge management. The CAIB Report said that NASA has knowledge management. The CAIB Report said that NASA has knowledge management. The CAIB Report said that NASA has knowledge management. The CAIB Report said that NASA has knowledge management. The CAIB Report said that NASA has knowledge management. The CAIB Report said that NASA has knowledge management. The CAIB Report said that NASA has knowledge management. The CAIB Report said that NASA has “dysfunctional databases.” Since NASA has a geographically “dysfunctional databases.” Since NASA has a geographically “dysfunctional databases.” Since NASA has a geographically “dysfunctional databases.” Since NASA has a geographically “dysfunctional databases.” Since NASA has a geographically “dysfunctional databases.” Since NASA has a geographically “dysfunctional databases.” Since NASA has a geographically “dysfunctional databases.” Since NASA has a geographically “dysfunctional databases.” Since NASA has a geographically “dysfunctional databases.” Since NASA has a geographically “dysfunctional databases.” Since NASA has a geographically “dysfunctional databases.” Since NASA has a geographically dispersed organization consisting of a relatively small Headquar-dispersed organization consisting of a relatively small Headquar-dispersed organization consisting of a relatively small Headquar-dispersed organization consisting of a relatively small Headquar-dispersed organization consisting of a relatively small Headquar-dispersed organization consisting of a relatively small Headquar-dispersed organization consisting of a relatively small Headquar-dispersed organization consisting of a relatively small Headquar-dispersed organization consisting of a relatively small Headquar-dispersed organization consisting of a relatively small Headquar-dispersed organization consisting of a relatively small Headquar-dispersed organization consisting of a relatively small Headquar-dispersed organization consisting of a relatively small Headquar-ters with many Center facilities around the country, a suitable ters with many Center facilities around the country, a suitable ters with many Center facilities around the country, a suitable ters with many Center facilities around the country, a suitable ters with many Center facilities around the country, a suitable ters with many Center facilities around the country, a suitable ters with many Center facilities around the country, a suitable ters with many Center facilities around the country, a suitable ters with many Center facilities around the country, a suitable ters with many Center facilities around the country, a suitable ters with many Center facilities around the country, a suitable ters with many Center facilities around the country, a suitable information storage and transfer system is essential to facilitate information storage and transfer system is essential to facilitate information storage and transfer system is essential to facilitate information storage and transfer system is essential to facilitate information storage and transfer system is essential to facilitate information storage and transfer system is essential to facilitate information storage and transfer system is essential to facilitate information storage and transfer system is essential to facilitate information storage and transfer system is essential to facilitate information storage and transfer system is essential to facilitate information storage and transfer system is essential to facilitate information storage and transfer system is essential to facilitate information storage and transfer system is essential to facilitate communication and learning. The CAIB had this to say:communication and learning. The CAIB had this to say:communication and learning. The CAIB had this to say:communication and learning. The CAIB had this to say:communication and learning. The CAIB had this to say:communication and learning. The CAIB had this to say:communication and learning. The CAIB had this to say:communication and learning. The CAIB had this to say:communication and learning. The CAIB had this to say:communication and learning. The CAIB had this to say:

In its investigation, the Board found that the information In its investigation, the Board found that the information In its investigation, the Board found that the information In its investigation, the Board found that the information In its investigation, the Board found that the information In its investigation, the Board found that the information In its investigation, the Board found that the information In its investigation, the Board found that the information In its investigation, the Board found that the information In its investigation, the Board found that the information systems that support the Shuttle Program are extremely systems that support the Shuttle Program are extremely systems that support the Shuttle Program are extremely systems that support the Shuttle Program are extremely systems that support the Shuttle Program are extremely systems that support the Shuttle Program are extremely systems that support the Shuttle Program are extremely systems that support the Shuttle Program are extremely systems that support the Shuttle Program are extremely systems that support the Shuttle Program are extremely cumbersome and diffi cult to use in decision-making at cumbersome and diffi cult to use in decision-making at cumbersome and diffi cult to use in decision-making at cumbersome and diffi cult to use in decision-making at cumbersome and diffi cult to use in decision-making at cumbersome and diffi cult to use in decision-making at cumbersome and diffi cult to use in decision-making at cumbersome and diffi cult to use in decision-making at cumbersome and diffi cult to use in decision-making at cumbersome and diffi cult to use in decision-making at cumbersome and diffi cult to use in decision-making at any level. For obvious reasons, these shortcomings any level. For obvious reasons, these shortcomings any level. For obvious reasons, these shortcomings any level. For obvious reasons, these shortcomings any level. For obvious reasons, these shortcomings any level. For obvious reasons, these shortcomings any level. For obvious reasons, these shortcomings any level. For obvious reasons, these shortcomings any level. For obvious reasons, these shortcomings any level. For obvious reasons, these shortcomings imperil the Shuttle Program’s ability to disseminate and imperil the Shuttle Program’s ability to disseminate and imperil the Shuttle Program’s ability to disseminate and imperil the Shuttle Program’s ability to disseminate and imperil the Shuttle Program’s ability to disseminate and imperil the Shuttle Program’s ability to disseminate and imperil the Shuttle Program’s ability to disseminate and imperil the Shuttle Program’s ability to disseminate and imperil the Shuttle Program’s ability to disseminate and imperil the Shuttle Program’s ability to disseminate and imperil the Shuttle Program’s ability to disseminate and share critical information among its many layers. (CAIB share critical information among its many layers. (CAIB share critical information among its many layers. (CAIB share critical information among its many layers. (CAIB share critical information among its many layers. (CAIB share critical information among its many layers. (CAIB share critical information among its many layers. (CAIB share critical information among its many layers. (CAIB share critical information among its many layers. (CAIB share critical information among its many layers. (CAIB Report, Chapter 7, p. 189)Report, Chapter 7, p. 189)Report, Chapter 7, p. 189)Report, Chapter 7, p. 189)Report, Chapter 7, p. 189)Report, Chapter 7, p. 189)

NASA personnel need to achieve a high level of technical and NASA personnel need to achieve a high level of technical and NASA personnel need to achieve a high level of technical and NASA personnel need to achieve a high level of technical and NASA personnel need to achieve a high level of technical and NASA personnel need to achieve a high level of technical and NASA personnel need to achieve a high level of technical and NASA personnel need to achieve a high level of technical and NASA personnel need to achieve a high level of technical and NASA personnel need to achieve a high level of technical and NASA personnel need to achieve a high level of technical and NASA personnel need to achieve a high level of technical and managerial competency along with a high state of readiness to managerial competency along with a high state of readiness to managerial competency along with a high state of readiness to managerial competency along with a high state of readiness to managerial competency along with a high state of readiness to managerial competency along with a high state of readiness to managerial competency along with a high state of readiness to managerial competency along with a high state of readiness to managerial competency along with a high state of readiness to managerial competency along with a high state of readiness to managerial competency along with a high state of readiness to managerial competency along with a high state of readiness to deal with the research, developmental, and operational challeng-deal with the research, developmental, and operational challeng-deal with the research, developmental, and operational challeng-deal with the research, developmental, and operational challeng-deal with the research, developmental, and operational challeng-deal with the research, developmental, and operational challeng-deal with the research, developmental, and operational challeng-deal with the research, developmental, and operational challeng-deal with the research, developmental, and operational challeng-deal with the research, developmental, and operational challeng-deal with the research, developmental, and operational challeng-deal with the research, developmental, and operational challeng-es inherent in the aerospace systems they manage and operate. In es inherent in the aerospace systems they manage and operate. In es inherent in the aerospace systems they manage and operate. In es inherent in the aerospace systems they manage and operate. In es inherent in the aerospace systems they manage and operate. In es inherent in the aerospace systems they manage and operate. In es inherent in the aerospace systems they manage and operate. In es inherent in the aerospace systems they manage and operate. In es inherent in the aerospace systems they manage and operate. In es inherent in the aerospace systems they manage and operate. In es inherent in the aerospace systems they manage and operate. In es inherent in the aerospace systems they manage and operate. In es inherent in the aerospace systems they manage and operate. In concert, the technical tools, information systems, and knowledge concert, the technical tools, information systems, and knowledge concert, the technical tools, information systems, and knowledge concert, the technical tools, information systems, and knowledge concert, the technical tools, information systems, and knowledge concert, the technical tools, information systems, and knowledge concert, the technical tools, information systems, and knowledge concert, the technical tools, information systems, and knowledge concert, the technical tools, information systems, and knowledge concert, the technical tools, information systems, and knowledge concert, the technical tools, information systems, and knowledge concert, the technical tools, information systems, and knowledge repositories of the Agency must be up to date and readily avail-repositories of the Agency must be up to date and readily avail-repositories of the Agency must be up to date and readily avail-repositories of the Agency must be up to date and readily avail-repositories of the Agency must be up to date and readily avail-repositories of the Agency must be up to date and readily avail-repositories of the Agency must be up to date and readily avail-repositories of the Agency must be up to date and readily avail-repositories of the Agency must be up to date and readily avail-repositories of the Agency must be up to date and readily avail-repositories of the Agency must be up to date and readily avail-repositories of the Agency must be up to date and readily avail-repositories of the Agency must be up to date and readily avail-

able to be used by personnel across the Agency. NASA can ex-able to be used by personnel across the Agency. NASA can ex-able to be used by personnel across the Agency. NASA can ex-able to be used by personnel across the Agency. NASA can ex-able to be used by personnel across the Agency. NASA can ex-able to be used by personnel across the Agency. NASA can ex-able to be used by personnel across the Agency. NASA can ex-able to be used by personnel across the Agency. NASA can ex-able to be used by personnel across the Agency. NASA can ex-able to be used by personnel across the Agency. NASA can ex-able to be used by personnel across the Agency. NASA can ex-able to be used by personnel across the Agency. NASA can ex-plore personnel training and learning through a variety of meth-plore personnel training and learning through a variety of meth-plore personnel training and learning through a variety of meth-plore personnel training and learning through a variety of meth-plore personnel training and learning through a variety of meth-plore personnel training and learning through a variety of meth-plore personnel training and learning through a variety of meth-plore personnel training and learning through a variety of meth-plore personnel training and learning through a variety of meth-plore personnel training and learning through a variety of meth-plore personnel training and learning through a variety of meth-plore personnel training and learning through a variety of meth-plore personnel training and learning through a variety of meth-ods. More on-the-job training through apprenticeship programs ods. More on-the-job training through apprenticeship programs ods. More on-the-job training through apprenticeship programs ods. More on-the-job training through apprenticeship programs ods. More on-the-job training through apprenticeship programs ods. More on-the-job training through apprenticeship programs ods. More on-the-job training through apprenticeship programs ods. More on-the-job training through apprenticeship programs ods. More on-the-job training through apprenticeship programs ods. More on-the-job training through apprenticeship programs ods. More on-the-job training through apprenticeship programs ods. More on-the-job training through apprenticeship programs and hands-on work can be emphasized for critical skills being and hands-on work can be emphasized for critical skills being and hands-on work can be emphasized for critical skills being and hands-on work can be emphasized for critical skills being and hands-on work can be emphasized for critical skills being and hands-on work can be emphasized for critical skills being and hands-on work can be emphasized for critical skills being and hands-on work can be emphasized for critical skills being and hands-on work can be emphasized for critical skills being and hands-on work can be emphasized for critical skills being and hands-on work can be emphasized for critical skills being and hands-on work can be emphasized for critical skills being and hands-on work can be emphasized for critical skills being lost at the Centers. In addition, comprehensive and systematic lost at the Centers. In addition, comprehensive and systematic lost at the Centers. In addition, comprehensive and systematic lost at the Centers. In addition, comprehensive and systematic lost at the Centers. In addition, comprehensive and systematic lost at the Centers. In addition, comprehensive and systematic lost at the Centers. In addition, comprehensive and systematic lost at the Centers. In addition, comprehensive and systematic lost at the Centers. In addition, comprehensive and systematic lost at the Centers. In addition, comprehensive and systematic lost at the Centers. In addition, comprehensive and systematic lost at the Centers. In addition, comprehensive and systematic emergency response training simulating the work environment, emergency response training simulating the work environment, emergency response training simulating the work environment, emergency response training simulating the work environment, emergency response training simulating the work environment, emergency response training simulating the work environment, emergency response training simulating the work environment, emergency response training simulating the work environment, emergency response training simulating the work environment, emergency response training simulating the work environment, emergency response training simulating the work environment, emergency response training simulating the work environment, emergency response training simulating the work environment, as well as hands-on experience, are critical to creating a learning as well as hands-on experience, are critical to creating a learning as well as hands-on experience, are critical to creating a learning as well as hands-on experience, are critical to creating a learning as well as hands-on experience, are critical to creating a learning as well as hands-on experience, are critical to creating a learning as well as hands-on experience, are critical to creating a learning as well as hands-on experience, are critical to creating a learning as well as hands-on experience, are critical to creating a learning as well as hands-on experience, are critical to creating a learning as well as hands-on experience, are critical to creating a learning as well as hands-on experience, are critical to creating a learning organization. organization. organization. organization. organization.

The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced the Diaz Team assessment:the Diaz Team assessment:the Diaz Team assessment:the Diaz Team assessment:the Diaz Team assessment:the Diaz Team assessment:the Diaz Team assessment:

»» Mandate that current and new employees moving into Mandate that current and new employees moving into Mandate that current and new employees moving into Mandate that current and new employees moving into Mandate that current and new employees moving into Mandate that current and new employees moving into Mandate that current and new employees moving into Mandate that current and new employees moving into Mandate that current and new employees moving into Mandate that current and new employees moving into management positions attend a lecture (sponsored by management positions attend a lecture (sponsored by management positions attend a lecture (sponsored by management positions attend a lecture (sponsored by management positions attend a lecture (sponsored by management positions attend a lecture (sponsored by management positions attend a lecture (sponsored by management positions attend a lecture (sponsored by management positions attend a lecture (sponsored by NASA) outlining historical lessons learned by NASA NASA) outlining historical lessons learned by NASA NASA) outlining historical lessons learned by NASA NASA) outlining historical lessons learned by NASA NASA) outlining historical lessons learned by NASA NASA) outlining historical lessons learned by NASA NASA) outlining historical lessons learned by NASA NASA) outlining historical lessons learned by NASA NASA) outlining historical lessons learned by NASA NASA) outlining historical lessons learned by NASA and comparable agencies. This lecture should be at and comparable agencies. This lecture should be at and comparable agencies. This lecture should be at and comparable agencies. This lecture should be at and comparable agencies. This lecture should be at and comparable agencies. This lecture should be at and comparable agencies. This lecture should be at and comparable agencies. This lecture should be at and comparable agencies. This lecture should be at least one day long and should cover lessons learned in least one day long and should cover lessons learned in least one day long and should cover lessons learned in least one day long and should cover lessons learned in least one day long and should cover lessons learned in least one day long and should cover lessons learned in least one day long and should cover lessons learned in least one day long and should cover lessons learned in least one day long and should cover lessons learned in several disasters (several disasters (several disasters (several disasters (ChallengerChallenger, , ColumbiaColumbia, Apollo 1Apollo 1Apollo 1, USS USS ThresherThresher) and close calls (i.e. STS-93 and ) and close calls (i.e. STS-93 and ) and close calls (i.e. STS-93 and ) and close calls (i.e. STS-93 and ) and close calls (i.e. STS-93 and ) and close calls (i.e. STS-93 and Apollo 13Apollo 13).

» NASA should routinely run mock mishap investiga-NASA should routinely run mock mishap investiga-NASA should routinely run mock mishap investiga-NASA should routinely run mock mishap investiga-NASA should routinely run mock mishap investiga-NASA should routinely run mock mishap investiga-NASA should routinely run mock mishap investiga-NASA should routinely run mock mishap investiga-NASA should routinely run mock mishap investiga-NASA should routinely run mock mishap investiga-tions to root out its process, product, and programmatic tions to root out its process, product, and programmatic tions to root out its process, product, and programmatic tions to root out its process, product, and programmatic tions to root out its process, product, and programmatic tions to root out its process, product, and programmatic tions to root out its process, product, and programmatic tions to root out its process, product, and programmatic tions to root out its process, product, and programmatic tions to root out its process, product, and programmatic weaknesses before a mishap actually happens.weaknesses before a mishap actually happens.weaknesses before a mishap actually happens.weaknesses before a mishap actually happens.weaknesses before a mishap actually happens.weaknesses before a mishap actually happens.weaknesses before a mishap actually happens.weaknesses before a mishap actually happens.weaknesses before a mishap actually happens.

» NASA does not effectively transfer knowledge. NASA NASA does not effectively transfer knowledge. NASA NASA does not effectively transfer knowledge. NASA NASA does not effectively transfer knowledge. NASA NASA does not effectively transfer knowledge. NASA NASA does not effectively transfer knowledge. NASA NASA does not effectively transfer knowledge. NASA NASA does not effectively transfer knowledge. NASA NASA does not effectively transfer knowledge. NASA NASA does not effectively transfer knowledge. NASA can signifi cantly improve our knowledge management can signifi cantly improve our knowledge management can signifi cantly improve our knowledge management can signifi cantly improve our knowledge management can signifi cantly improve our knowledge management can signifi cantly improve our knowledge management can signifi cantly improve our knowledge management can signifi cantly improve our knowledge management can signifi cantly improve our knowledge management can signifi cantly improve our knowledge management can signifi cantly improve our knowledge management culture with lessons learned processes, trend analyses, culture with lessons learned processes, trend analyses, culture with lessons learned processes, trend analyses, culture with lessons learned processes, trend analyses, culture with lessons learned processes, trend analyses, culture with lessons learned processes, trend analyses, culture with lessons learned processes, trend analyses, culture with lessons learned processes, trend analyses, culture with lessons learned processes, trend analyses, culture with lessons learned processes, trend analyses, transferring expert knowledge from people to systems, transferring expert knowledge from people to systems, transferring expert knowledge from people to systems, transferring expert knowledge from people to systems, transferring expert knowledge from people to systems, transferring expert knowledge from people to systems, transferring expert knowledge from people to systems, transferring expert knowledge from people to systems, transferring expert knowledge from people to systems, transferring expert knowledge from people to systems, and portals that share information.and portals that share information.and portals that share information.and portals that share information.and portals that share information.and portals that share information.and portals that share information.

» NASA should employ a more rigorous/disciplined ac-NASA should employ a more rigorous/disciplined ac-NASA should employ a more rigorous/disciplined ac-NASA should employ a more rigorous/disciplined ac-NASA should employ a more rigorous/disciplined ac-NASA should employ a more rigorous/disciplined ac-NASA should employ a more rigorous/disciplined ac-NASA should employ a more rigorous/disciplined ac-NASA should employ a more rigorous/disciplined ac-NASA should employ a more rigorous/disciplined ac-ceptance testing & checkout procedure prior to placing ceptance testing & checkout procedure prior to placing ceptance testing & checkout procedure prior to placing ceptance testing & checkout procedure prior to placing ceptance testing & checkout procedure prior to placing ceptance testing & checkout procedure prior to placing ceptance testing & checkout procedure prior to placing ceptance testing & checkout procedure prior to placing ceptance testing & checkout procedure prior to placing ceptance testing & checkout procedure prior to placing ceptance testing & checkout procedure prior to placing any system (hardware or software) in operation. The any system (hardware or software) in operation. The any system (hardware or software) in operation. The any system (hardware or software) in operation. The any system (hardware or software) in operation. The any system (hardware or software) in operation. The any system (hardware or software) in operation. The any system (hardware or software) in operation. The any system (hardware or software) in operation. The requirements and results should be kept in a database requirements and results should be kept in a database requirements and results should be kept in a database requirements and results should be kept in a database requirements and results should be kept in a database requirements and results should be kept in a database requirements and results should be kept in a database requirements and results should be kept in a database requirements and results should be kept in a database requirements and results should be kept in a database with an independent group auditing input.with an independent group auditing input.with an independent group auditing input.with an independent group auditing input.with an independent group auditing input.with an independent group auditing input.with an independent group auditing input.with an independent group auditing input.

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

1.1.1. Developing and using an Agency-wide knowledge Developing and using an Agency-wide knowledge Developing and using an Agency-wide knowledge Developing and using an Agency-wide knowledge Developing and using an Agency-wide knowledge Developing and using an Agency-wide knowledge Developing and using an Agency-wide knowledge Developing and using an Agency-wide knowledge Developing and using an Agency-wide knowledge Developing and using an Agency-wide knowledge management system to foster sound decision-mak-management system to foster sound decision-mak-management system to foster sound decision-mak-management system to foster sound decision-mak-management system to foster sound decision-mak-management system to foster sound decision-mak-management system to foster sound decision-mak-management system to foster sound decision-mak-management system to foster sound decision-mak-ing practices. Programs must have the ability to share ing practices. Programs must have the ability to share ing practices. Programs must have the ability to share ing practices. Programs must have the ability to share ing practices. Programs must have the ability to share ing practices. Programs must have the ability to share ing practices. Programs must have the ability to share ing practices. Programs must have the ability to share ing practices. Programs must have the ability to share ing practices. Programs must have the ability to share ing practices. Programs must have the ability to share information using central databases.information using central databases.information using central databases.information using central databases.information using central databases.information using central databases.information using central databases.

2.2.2. Requiring programs to have contingency and emer-Requiring programs to have contingency and emer-Requiring programs to have contingency and emer-Requiring programs to have contingency and emer-Requiring programs to have contingency and emer-Requiring programs to have contingency and emer-Requiring programs to have contingency and emer-Requiring programs to have contingency and emer-Requiring programs to have contingency and emer-Requiring programs to have contingency and emer-gency response processes in place, and requiring the gency response processes in place, and requiring the gency response processes in place, and requiring the gency response processes in place, and requiring the gency response processes in place, and requiring the gency response processes in place, and requiring the gency response processes in place, and requiring the gency response processes in place, and requiring the gency response processes in place, and requiring the programs to conduct rigorous and ongoing training in programs to conduct rigorous and ongoing training in programs to conduct rigorous and ongoing training in programs to conduct rigorous and ongoing training in programs to conduct rigorous and ongoing training in programs to conduct rigorous and ongoing training in programs to conduct rigorous and ongoing training in programs to conduct rigorous and ongoing training in programs to conduct rigorous and ongoing training in programs to conduct rigorous and ongoing training in those processes. those processes. those processes. those processes.

In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address each R-O-F, the Diaz Team has one goal addressing the Learning each R-O-F, the Diaz Team has one goal addressing the Learning each R-O-F, the Diaz Team has one goal addressing the Learning each R-O-F, the Diaz Team has one goal addressing the Learning each R-O-F, the Diaz Team has one goal addressing the Learning each R-O-F, the Diaz Team has one goal addressing the Learning each R-O-F, the Diaz Team has one goal addressing the Learning each R-O-F, the Diaz Team has one goal addressing the Learning each R-O-F, the Diaz Team has one goal addressing the Learning each R-O-F, the Diaz Team has one goal addressing the Learning each R-O-F, the Diaz Team has one goal addressing the Learning each R-O-F, the Diaz Team has one goal addressing the Learning category, as shown in Table 3.category, as shown in Table 3.category, as shown in Table 3.category, as shown in Table 3.category, as shown in Table 3.category, as shown in Table 3.category, as shown in Table 3.

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

Learning – Diaz Team Goal

The Agency should identify an appropriate approach for the future development of a knowledge management system and infrastructure to assure knowledge retention and lessons learned.

1 21 2

CAIB Report Chapter 6, p170:Management decisions made during Columbia’s fi nal fl ight refl ect missed opportunities, blocked or ineffective communication channels, fl awed analysis, and ineffective leadership. Perhaps most striking is the fact that management – including Shuttle Program, Mission Management Team, Mission Evaluation Room, and Flight Director and Mission Control – displayed no interest in understanding a problem and its implications.

1.4 COMMUNICATION

Communication did not fl ow effectively.

Agency-wide Themes• Anomalies should be considered problems until

proven otherwise.• Responsibility, authority, and accountability must

be clearly understood and communicated.• Communications need to fl ow both up and down

the chain of command.• Diverse viewpoints must be fostered and minor-

ity views considered.• Communication practices must be validated and

tested to ensure effective communication across NASA.

The CAIB Report discussed communication at all levels. The The CAIB Report discussed communication at all levels. The The CAIB Report discussed communication at all levels. The The CAIB Report discussed communication at all levels. The The CAIB Report discussed communication at all levels. The The CAIB Report discussed communication at all levels. The The CAIB Report discussed communication at all levels. The The CAIB Report discussed communication at all levels. The The CAIB Report discussed communication at all levels. The The CAIB Report discussed communication at all levels. The The CAIB Report discussed communication at all levels. The The CAIB Report discussed communication at all levels. The lack of effective communication from Headquarters to every lack of effective communication from Headquarters to every lack of effective communication from Headquarters to every lack of effective communication from Headquarters to every lack of effective communication from Headquarters to every lack of effective communication from Headquarters to every lack of effective communication from Headquarters to every lack of effective communication from Headquarters to every lack of effective communication from Headquarters to every lack of effective communication from Headquarters to every lack of effective communication from Headquarters to every lack of effective communication from Headquarters to every member of the NASA workforce is a continuing problem, and member of the NASA workforce is a continuing problem, and member of the NASA workforce is a continuing problem, and member of the NASA workforce is a continuing problem, and member of the NASA workforce is a continuing problem, and member of the NASA workforce is a continuing problem, and member of the NASA workforce is a continuing problem, and member of the NASA workforce is a continuing problem, and member of the NASA workforce is a continuing problem, and member of the NASA workforce is a continuing problem, and member of the NASA workforce is a continuing problem, and member of the NASA workforce is a continuing problem, and member of the NASA workforce is a continuing problem, and was stressed in the Safety and Mission Success Week feedback. was stressed in the Safety and Mission Success Week feedback. was stressed in the Safety and Mission Success Week feedback. was stressed in the Safety and Mission Success Week feedback. was stressed in the Safety and Mission Success Week feedback. was stressed in the Safety and Mission Success Week feedback. was stressed in the Safety and Mission Success Week feedback. was stressed in the Safety and Mission Success Week feedback. was stressed in the Safety and Mission Success Week feedback. was stressed in the Safety and Mission Success Week feedback. was stressed in the Safety and Mission Success Week feedback. was stressed in the Safety and Mission Success Week feedback. This is what the CAIB had to say about communication: This is what the CAIB had to say about communication: This is what the CAIB had to say about communication: This is what the CAIB had to say about communication: This is what the CAIB had to say about communication: This is what the CAIB had to say about communication: This is what the CAIB had to say about communication: This is what the CAIB had to say about communication: This is what the CAIB had to say about communication: This is what the CAIB had to say about communication: This is what the CAIB had to say about communication:

The organizational structure and hierarchy blocked effec-The organizational structure and hierarchy blocked effec-The organizational structure and hierarchy blocked effec-The organizational structure and hierarchy blocked effec-The organizational structure and hierarchy blocked effec-The organizational structure and hierarchy blocked effec-The organizational structure and hierarchy blocked effec-The organizational structure and hierarchy blocked effec-The organizational structure and hierarchy blocked effec-The organizational structure and hierarchy blocked effec-The organizational structure and hierarchy blocked effec-tive communication of technical problems. Signals were tive communication of technical problems. Signals were tive communication of technical problems. Signals were tive communication of technical problems. Signals were tive communication of technical problems. Signals were tive communication of technical problems. Signals were tive communication of technical problems. Signals were tive communication of technical problems. Signals were tive communication of technical problems. Signals were tive communication of technical problems. Signals were over-looked, people were silenced, and useful information over-looked, people were silenced, and useful information over-looked, people were silenced, and useful information over-looked, people were silenced, and useful information over-looked, people were silenced, and useful information over-looked, people were silenced, and useful information over-looked, people were silenced, and useful information over-looked, people were silenced, and useful information over-looked, people were silenced, and useful information over-looked, people were silenced, and useful information and dissenting views on technical issues did not surface and dissenting views on technical issues did not surface and dissenting views on technical issues did not surface and dissenting views on technical issues did not surface and dissenting views on technical issues did not surface and dissenting views on technical issues did not surface and dissenting views on technical issues did not surface and dissenting views on technical issues did not surface and dissenting views on technical issues did not surface and dissenting views on technical issues did not surface and dissenting views on technical issues did not surface at higher levels. (CAIB Report, Chapter 8, p. 201)at higher levels. (CAIB Report, Chapter 8, p. 201)at higher levels. (CAIB Report, Chapter 8, p. 201)at higher levels. (CAIB Report, Chapter 8, p. 201)at higher levels. (CAIB Report, Chapter 8, p. 201)at higher levels. (CAIB Report, Chapter 8, p. 201)at higher levels. (CAIB Report, Chapter 8, p. 201)at higher levels. (CAIB Report, Chapter 8, p. 201)at higher levels. (CAIB Report, Chapter 8, p. 201)

When broadly applied, the Diaz Team actions for Communica-When broadly applied, the Diaz Team actions for Communica-When broadly applied, the Diaz Team actions for Communica-When broadly applied, the Diaz Team actions for Communica-When broadly applied, the Diaz Team actions for Communica-When broadly applied, the Diaz Team actions for Communica-When broadly applied, the Diaz Team actions for Communica-When broadly applied, the Diaz Team actions for Communica-When broadly applied, the Diaz Team actions for Communica-When broadly applied, the Diaz Team actions for Communica-When broadly applied, the Diaz Team actions for Communica-When broadly applied, the Diaz Team actions for Communica-tion focus on developing a management and communication tion focus on developing a management and communication tion focus on developing a management and communication tion focus on developing a management and communication tion focus on developing a management and communication tion focus on developing a management and communication tion focus on developing a management and communication tion focus on developing a management and communication tion focus on developing a management and communication tion focus on developing a management and communication tion focus on developing a management and communication tion focus on developing a management and communication tion focus on developing a management and communication culture that is based on adequate discourse for anomaly reso-culture that is based on adequate discourse for anomaly reso-culture that is based on adequate discourse for anomaly reso-culture that is based on adequate discourse for anomaly reso-culture that is based on adequate discourse for anomaly reso-culture that is based on adequate discourse for anomaly reso-culture that is based on adequate discourse for anomaly reso-culture that is based on adequate discourse for anomaly reso-culture that is based on adequate discourse for anomaly reso-culture that is based on adequate discourse for anomaly reso-culture that is based on adequate discourse for anomaly reso-culture that is based on adequate discourse for anomaly reso-lution, a clear process for chain of command and contingency lution, a clear process for chain of command and contingency lution, a clear process for chain of command and contingency lution, a clear process for chain of command and contingency lution, a clear process for chain of command and contingency lution, a clear process for chain of command and contingency lution, a clear process for chain of command and contingency lution, a clear process for chain of command and contingency lution, a clear process for chain of command and contingency lution, a clear process for chain of command and contingency lution, a clear process for chain of command and contingency lution, a clear process for chain of command and contingency lution, a clear process for chain of command and contingency communication, and the codifi cation of formal communication communication, and the codifi cation of formal communication communication, and the codifi cation of formal communication communication, and the codifi cation of formal communication communication, and the codifi cation of formal communication communication, and the codifi cation of formal communication communication, and the codifi cation of formal communication communication, and the codifi cation of formal communication communication, and the codifi cation of formal communication communication, and the codifi cation of formal communication communication, and the codifi cation of formal communication communication, and the codifi cation of formal communication and reporting policies and procedures. This cultural change re-and reporting policies and procedures. This cultural change re-and reporting policies and procedures. This cultural change re-and reporting policies and procedures. This cultural change re-and reporting policies and procedures. This cultural change re-and reporting policies and procedures. This cultural change re-and reporting policies and procedures. This cultural change re-and reporting policies and procedures. This cultural change re-and reporting policies and procedures. This cultural change re-and reporting policies and procedures. This cultural change re-and reporting policies and procedures. This cultural change re-and reporting policies and procedures. This cultural change re-quires that NASA return to the process that considers anomalies quires that NASA return to the process that considers anomalies quires that NASA return to the process that considers anomalies quires that NASA return to the process that considers anomalies quires that NASA return to the process that considers anomalies quires that NASA return to the process that considers anomalies quires that NASA return to the process that considers anomalies quires that NASA return to the process that considers anomalies quires that NASA return to the process that considers anomalies quires that NASA return to the process that considers anomalies quires that NASA return to the process that considers anomalies quires that NASA return to the process that considers anomalies quires that NASA return to the process that considers anomalies as problems until proven otherwise. This philosophy, supported as problems until proven otherwise. This philosophy, supported as problems until proven otherwise. This philosophy, supported as problems until proven otherwise. This philosophy, supported as problems until proven otherwise. This philosophy, supported as problems until proven otherwise. This philosophy, supported as problems until proven otherwise. This philosophy, supported as problems until proven otherwise. This philosophy, supported as problems until proven otherwise. This philosophy, supported as problems until proven otherwise. This philosophy, supported as problems until proven otherwise. This philosophy, supported as problems until proven otherwise. This philosophy, supported by a clear chain of command also supports contingency com-by a clear chain of command also supports contingency com-by a clear chain of command also supports contingency com-by a clear chain of command also supports contingency com-by a clear chain of command also supports contingency com-by a clear chain of command also supports contingency com-by a clear chain of command also supports contingency com-by a clear chain of command also supports contingency com-by a clear chain of command also supports contingency com-by a clear chain of command also supports contingency com-by a clear chain of command also supports contingency com-by a clear chain of command also supports contingency com-by a clear chain of command also supports contingency com-munication, or escalation paths, so that disagreements can be munication, or escalation paths, so that disagreements can be munication, or escalation paths, so that disagreements can be munication, or escalation paths, so that disagreements can be munication, or escalation paths, so that disagreements can be munication, or escalation paths, so that disagreements can be munication, or escalation paths, so that disagreements can be munication, or escalation paths, so that disagreements can be munication, or escalation paths, so that disagreements can be munication, or escalation paths, so that disagreements can be munication, or escalation paths, so that disagreements can be munication, or escalation paths, so that disagreements can be addressed to enhance anomaly resolution. addressed to enhance anomaly resolution. addressed to enhance anomaly resolution. addressed to enhance anomaly resolution. addressed to enhance anomaly resolution. addressed to enhance anomaly resolution. addressed to enhance anomaly resolution. addressed to enhance anomaly resolution. addressed to enhance anomaly resolution.

The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced the Diaz Team assessment:the Diaz Team assessment:the Diaz Team assessment:the Diaz Team assessment:the Diaz Team assessment:the Diaz Team assessment:

»» When concerns are raised, the prevailing attitude in When concerns are raised, the prevailing attitude in When concerns are raised, the prevailing attitude in When concerns are raised, the prevailing attitude in When concerns are raised, the prevailing attitude in When concerns are raised, the prevailing attitude in When concerns are raised, the prevailing attitude in When concerns are raised, the prevailing attitude in When concerns are raised, the prevailing attitude in When concerns are raised, the prevailing attitude in NASA management is to require the concerned person NASA management is to require the concerned person NASA management is to require the concerned person NASA management is to require the concerned person NASA management is to require the concerned person NASA management is to require the concerned person NASA management is to require the concerned person NASA management is to require the concerned person NASA management is to require the concerned person or organization prove that something is a problem or organization prove that something is a problem or organization prove that something is a problem or organization prove that something is a problem or organization prove that something is a problem or organization prove that something is a problem or organization prove that something is a problem or organization prove that something is a problem or organization prove that something is a problem or organization prove that something is a problem before action will be taken. The action may be just before action will be taken. The action may be just before action will be taken. The action may be just before action will be taken. The action may be just before action will be taken. The action may be just before action will be taken. The action may be just before action will be taken. The action may be just before action will be taken. The action may be just before action will be taken. The action may be just

more analysis and testing. If the concerned person or more analysis and testing. If the concerned person or more analysis and testing. If the concerned person or more analysis and testing. If the concerned person or more analysis and testing. If the concerned person or more analysis and testing. If the concerned person or more analysis and testing. If the concerned person or more analysis and testing. If the concerned person or more analysis and testing. If the concerned person or more analysis and testing. If the concerned person or organization cannot furnish data to prove a problem organization cannot furnish data to prove a problem organization cannot furnish data to prove a problem organization cannot furnish data to prove a problem organization cannot furnish data to prove a problem organization cannot furnish data to prove a problem organization cannot furnish data to prove a problem organization cannot furnish data to prove a problem organization cannot furnish data to prove a problem exists, no action will be taken.exists, no action will be taken.exists, no action will be taken.exists, no action will be taken.exists, no action will be taken.exists, no action will be taken.exists, no action will be taken.

» One of the barriers that should be broken down is the One of the barriers that should be broken down is the One of the barriers that should be broken down is the One of the barriers that should be broken down is the One of the barriers that should be broken down is the One of the barriers that should be broken down is the One of the barriers that should be broken down is the One of the barriers that should be broken down is the One of the barriers that should be broken down is the communication barrier. The NASA workforce should communication barrier. The NASA workforce should communication barrier. The NASA workforce should communication barrier. The NASA workforce should communication barrier. The NASA workforce should communication barrier. The NASA workforce should communication barrier. The NASA workforce should communication barrier. The NASA workforce should communication barrier. The NASA workforce should communication barrier. The NASA workforce should feel comfortable to bring forward comments. feel comfortable to bring forward comments. feel comfortable to bring forward comments. feel comfortable to bring forward comments. feel comfortable to bring forward comments. feel comfortable to bring forward comments. feel comfortable to bring forward comments. feel comfortable to bring forward comments.

» Why is it not OK to ask Why?Why is it not OK to ask Why?Why is it not OK to ask Why?Why is it not OK to ask Why?Why is it not OK to ask Why?Why is it not OK to ask Why?Why is it not OK to ask Why?» There is fear of reprisal for openly communicating dis-There is fear of reprisal for openly communicating dis-There is fear of reprisal for openly communicating dis-There is fear of reprisal for openly communicating dis-There is fear of reprisal for openly communicating dis-There is fear of reprisal for openly communicating dis-There is fear of reprisal for openly communicating dis-There is fear of reprisal for openly communicating dis-There is fear of reprisal for openly communicating dis-There is fear of reprisal for openly communicating dis-

senting opinions.senting opinions.senting opinions.senting opinions.» Most are reluctant to say anything for fear of criticism Most are reluctant to say anything for fear of criticism Most are reluctant to say anything for fear of criticism Most are reluctant to say anything for fear of criticism Most are reluctant to say anything for fear of criticism Most are reluctant to say anything for fear of criticism Most are reluctant to say anything for fear of criticism Most are reluctant to say anything for fear of criticism Most are reluctant to say anything for fear of criticism Most are reluctant to say anything for fear of criticism Most are reluctant to say anything for fear of criticism

or they feel it isnʼt worth it. People have tried in the or they feel it isnʼt worth it. People have tried in the or they feel it isnʼt worth it. People have tried in the or they feel it isnʼt worth it. People have tried in the or they feel it isnʼt worth it. People have tried in the or they feel it isnʼt worth it. People have tried in the or they feel it isnʼt worth it. People have tried in the or they feel it isnʼt worth it. People have tried in the or they feel it isnʼt worth it. People have tried in the past to point things out but know itʼs not going to get past to point things out but know itʼs not going to get past to point things out but know itʼs not going to get past to point things out but know itʼs not going to get past to point things out but know itʼs not going to get past to point things out but know itʼs not going to get past to point things out but know itʼs not going to get past to point things out but know itʼs not going to get past to point things out but know itʼs not going to get past to point things out but know itʼs not going to get them anywhere. NASA culture does not encourage or them anywhere. NASA culture does not encourage or them anywhere. NASA culture does not encourage or them anywhere. NASA culture does not encourage or them anywhere. NASA culture does not encourage or them anywhere. NASA culture does not encourage or them anywhere. NASA culture does not encourage or them anywhere. NASA culture does not encourage or them anywhere. NASA culture does not encourage or them anywhere. NASA culture does not encourage or reward people who speak out.reward people who speak out.reward people who speak out.reward people who speak out.reward people who speak out.reward people who speak out.reward people who speak out.

» There is a lack of a formal and effective structure to There is a lack of a formal and effective structure to There is a lack of a formal and effective structure to There is a lack of a formal and effective structure to There is a lack of a formal and effective structure to There is a lack of a formal and effective structure to There is a lack of a formal and effective structure to There is a lack of a formal and effective structure to There is a lack of a formal and effective structure to facilitate information fl ow up and down the manage-facilitate information fl ow up and down the manage-facilitate information fl ow up and down the manage-facilitate information fl ow up and down the manage-facilitate information fl ow up and down the manage-facilitate information fl ow up and down the manage-facilitate information fl ow up and down the manage-facilitate information fl ow up and down the manage-facilitate information fl ow up and down the manage-ment chain.ment chain.ment chain.

The Safety and Mission Success feedback indicated a sense from The Safety and Mission Success feedback indicated a sense from The Safety and Mission Success feedback indicated a sense from The Safety and Mission Success feedback indicated a sense from The Safety and Mission Success feedback indicated a sense from The Safety and Mission Success feedback indicated a sense from The Safety and Mission Success feedback indicated a sense from The Safety and Mission Success feedback indicated a sense from The Safety and Mission Success feedback indicated a sense from The Safety and Mission Success feedback indicated a sense from The Safety and Mission Success feedback indicated a sense from The Safety and Mission Success feedback indicated a sense from some in the workforce that they have lost the ability to participate some in the workforce that they have lost the ability to participate some in the workforce that they have lost the ability to participate some in the workforce that they have lost the ability to participate some in the workforce that they have lost the ability to participate some in the workforce that they have lost the ability to participate some in the workforce that they have lost the ability to participate some in the workforce that they have lost the ability to participate some in the workforce that they have lost the ability to participate some in the workforce that they have lost the ability to participate some in the workforce that they have lost the ability to participate in the decision-making process. The feedback also suggests that in the decision-making process. The feedback also suggests that in the decision-making process. The feedback also suggests that in the decision-making process. The feedback also suggests that in the decision-making process. The feedback also suggests that in the decision-making process. The feedback also suggests that in the decision-making process. The feedback also suggests that in the decision-making process. The feedback also suggests that in the decision-making process. The feedback also suggests that in the decision-making process. The feedback also suggests that in the decision-making process. The feedback also suggests that in the decision-making process. The feedback also suggests that there is a segment of the workforce with the desire to participate there is a segment of the workforce with the desire to participate there is a segment of the workforce with the desire to participate there is a segment of the workforce with the desire to participate there is a segment of the workforce with the desire to participate there is a segment of the workforce with the desire to participate there is a segment of the workforce with the desire to participate there is a segment of the workforce with the desire to participate there is a segment of the workforce with the desire to participate there is a segment of the workforce with the desire to participate there is a segment of the workforce with the desire to participate but who are afraid to do so. They are uncertain about their roles, but who are afraid to do so. They are uncertain about their roles, but who are afraid to do so. They are uncertain about their roles, but who are afraid to do so. They are uncertain about their roles, but who are afraid to do so. They are uncertain about their roles, but who are afraid to do so. They are uncertain about their roles, but who are afraid to do so. They are uncertain about their roles, but who are afraid to do so. They are uncertain about their roles, but who are afraid to do so. They are uncertain about their roles, but who are afraid to do so. They are uncertain about their roles, but who are afraid to do so. They are uncertain about their roles, but who are afraid to do so. They are uncertain about their roles, and have a lack of understanding of the processes for dissent. and have a lack of understanding of the processes for dissent. and have a lack of understanding of the processes for dissent. and have a lack of understanding of the processes for dissent. and have a lack of understanding of the processes for dissent. and have a lack of understanding of the processes for dissent. and have a lack of understanding of the processes for dissent. and have a lack of understanding of the processes for dissent. and have a lack of understanding of the processes for dissent. and have a lack of understanding of the processes for dissent. and have a lack of understanding of the processes for dissent. In the Diaz Teamʼs analysis of the Safety and Mission Success In the Diaz Teamʼs analysis of the Safety and Mission Success In the Diaz Teamʼs analysis of the Safety and Mission Success In the Diaz Teamʼs analysis of the Safety and Mission Success In the Diaz Teamʼs analysis of the Safety and Mission Success In the Diaz Teamʼs analysis of the Safety and Mission Success In the Diaz Teamʼs analysis of the Safety and Mission Success In the Diaz Teamʼs analysis of the Safety and Mission Success In the Diaz Teamʼs analysis of the Safety and Mission Success In the Diaz Teamʼs analysis of the Safety and Mission Success In the Diaz Teamʼs analysis of the Safety and Mission Success Week data, problematic communication was a recurring theme Week data, problematic communication was a recurring theme Week data, problematic communication was a recurring theme Week data, problematic communication was a recurring theme Week data, problematic communication was a recurring theme Week data, problematic communication was a recurring theme Week data, problematic communication was a recurring theme Week data, problematic communication was a recurring theme Week data, problematic communication was a recurring theme Week data, problematic communication was a recurring theme Week data, problematic communication was a recurring theme Week data, problematic communication was a recurring theme from Headquarters and every Center. Communication has a from Headquarters and every Center. Communication has a from Headquarters and every Center. Communication has a from Headquarters and every Center. Communication has a from Headquarters and every Center. Communication has a from Headquarters and every Center. Communication has a from Headquarters and every Center. Communication has a from Headquarters and every Center. Communication has a from Headquarters and every Center. Communication has a from Headquarters and every Center. Communication has a from Headquarters and every Center. Communication has a chance to improve when:chance to improve when:chance to improve when:chance to improve when:chance to improve when:chance to improve when:

1.1.1. There is no fear of retribution.There is no fear of retribution.There is no fear of retribution.There is no fear of retribution.There is no fear of retribution.There is no fear of retribution.There is no fear of retribution.2.2. Information is considered in an unbiased manner.Information is considered in an unbiased manner.Information is considered in an unbiased manner.Information is considered in an unbiased manner.Information is considered in an unbiased manner.Information is considered in an unbiased manner.Information is considered in an unbiased manner.Information is considered in an unbiased manner.Information is considered in an unbiased manner.3.3. Every opinion is treated with respect.Every opinion is treated with respect.Every opinion is treated with respect.Every opinion is treated with respect.Every opinion is treated with respect.Every opinion is treated with respect.Every opinion is treated with respect.Every opinion is treated with respect.4.4. Decision feedback is provided.Decision feedback is provided.Decision feedback is provided.Decision feedback is provided.Decision feedback is provided.Decision feedback is provided.

The CAIB fi ndings and Diaz Team actions identify means to start The CAIB fi ndings and Diaz Team actions identify means to start The CAIB fi ndings and Diaz Team actions identify means to start The CAIB fi ndings and Diaz Team actions identify means to start The CAIB fi ndings and Diaz Team actions identify means to start The CAIB fi ndings and Diaz Team actions identify means to start The CAIB fi ndings and Diaz Team actions identify means to start The CAIB fi ndings and Diaz Team actions identify means to start The CAIB fi ndings and Diaz Team actions identify means to start The CAIB fi ndings and Diaz Team actions identify means to start The CAIB fi ndings and Diaz Team actions identify means to start The CAIB fi ndings and Diaz Team actions identify means to start building a more effective communication strategy. However, building a more effective communication strategy. However, building a more effective communication strategy. However, building a more effective communication strategy. However, building a more effective communication strategy. However, building a more effective communication strategy. However, building a more effective communication strategy. However, building a more effective communication strategy. However, building a more effective communication strategy. However, building a more effective communication strategy. However, building a more effective communication strategy. However, change in communication requires that leaders adopt differ-change in communication requires that leaders adopt differ-change in communication requires that leaders adopt differ-change in communication requires that leaders adopt differ-change in communication requires that leaders adopt differ-change in communication requires that leaders adopt differ-change in communication requires that leaders adopt differ-change in communication requires that leaders adopt differ-change in communication requires that leaders adopt differ-change in communication requires that leaders adopt differ-change in communication requires that leaders adopt differ-change in communication requires that leaders adopt differ-ent behavior and communication philosophies. Leaders should ent behavior and communication philosophies. Leaders should ent behavior and communication philosophies. Leaders should ent behavior and communication philosophies. Leaders should ent behavior and communication philosophies. Leaders should ent behavior and communication philosophies. Leaders should ent behavior and communication philosophies. Leaders should ent behavior and communication philosophies. Leaders should ent behavior and communication philosophies. Leaders should ent behavior and communication philosophies. Leaders should ent behavior and communication philosophies. Leaders should promote a diversity of viewpoints. Fear of retribution must be promote a diversity of viewpoints. Fear of retribution must be promote a diversity of viewpoints. Fear of retribution must be promote a diversity of viewpoints. Fear of retribution must be promote a diversity of viewpoints. Fear of retribution must be promote a diversity of viewpoints. Fear of retribution must be promote a diversity of viewpoints. Fear of retribution must be promote a diversity of viewpoints. Fear of retribution must be promote a diversity of viewpoints. Fear of retribution must be promote a diversity of viewpoints. Fear of retribution must be promote a diversity of viewpoints. Fear of retribution must be promote a diversity of viewpoints. Fear of retribution must be eliminated. The workforce needs a process to allow for dissent-eliminated. The workforce needs a process to allow for dissent-eliminated. The workforce needs a process to allow for dissent-eliminated. The workforce needs a process to allow for dissent-eliminated. The workforce needs a process to allow for dissent-eliminated. The workforce needs a process to allow for dissent-eliminated. The workforce needs a process to allow for dissent-eliminated. The workforce needs a process to allow for dissent-eliminated. The workforce needs a process to allow for dissent-eliminated. The workforce needs a process to allow for dissent-eliminated. The workforce needs a process to allow for dissent-ing opinion and intervention when retribution or retaliation is ing opinion and intervention when retribution or retaliation is ing opinion and intervention when retribution or retaliation is ing opinion and intervention when retribution or retaliation is ing opinion and intervention when retribution or retaliation is ing opinion and intervention when retribution or retaliation is ing opinion and intervention when retribution or retaliation is ing opinion and intervention when retribution or retaliation is ing opinion and intervention when retribution or retaliation is ing opinion and intervention when retribution or retaliation is ing opinion and intervention when retribution or retaliation is suspected. The new Agency Ombuds, recommended by the Diaz suspected. The new Agency Ombuds, recommended by the Diaz suspected. The new Agency Ombuds, recommended by the Diaz suspected. The new Agency Ombuds, recommended by the Diaz suspected. The new Agency Ombuds, recommended by the Diaz suspected. The new Agency Ombuds, recommended by the Diaz suspected. The new Agency Ombuds, recommended by the Diaz suspected. The new Agency Ombuds, recommended by the Diaz suspected. The new Agency Ombuds, recommended by the Diaz suspected. The new Agency Ombuds, recommended by the Diaz suspected. The new Agency Ombuds, recommended by the Diaz Team, should serve this purpose well. Team, should serve this purpose well. Team, should serve this purpose well. Team, should serve this purpose well. Team, should serve this purpose well. Team, should serve this purpose well. Team, should serve this purpose well.

In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address each R-O-F, the Diaz Team has one goal addressing the Commu-each R-O-F, the Diaz Team has one goal addressing the Commu-each R-O-F, the Diaz Team has one goal addressing the Commu-each R-O-F, the Diaz Team has one goal addressing the Commu-each R-O-F, the Diaz Team has one goal addressing the Commu-each R-O-F, the Diaz Team has one goal addressing the Commu-each R-O-F, the Diaz Team has one goal addressing the Commu-each R-O-F, the Diaz Team has one goal addressing the Commu-each R-O-F, the Diaz Team has one goal addressing the Commu-each R-O-F, the Diaz Team has one goal addressing the Commu-each R-O-F, the Diaz Team has one goal addressing the Commu-each R-O-F, the Diaz Team has one goal addressing the Commu-nication category, as shown in Table 4.nication category, as shown in Table 4.nication category, as shown in Table 4.nication category, as shown in Table 4.nication category, as shown in Table 4.nication category, as shown in Table 4.nication category, as shown in Table 4.

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

Communication – Diaz Team Goal

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

1 31 3

1.5 PROCESSES AND RULES

CAIB Report Chapter 8, p203:When it came to managers’ own actions, however, a different set of rules prevailed. The Board found that Mis-sion Management Team decision-making operated outside the rules even as it held its engineers to a stifl ing protocol. Management was not able to recognize that in unprecedented conditions, when lives are on the line, fl exibility and democratic process should take priority over bureaucratic response.

NASA has not followed its own rules.

Agency-wide Themes• Requirements, policies, procedures, and direc-

tives must be examined and adhered to.• Best practices and lessons learned must be

incorporated.• The entire workforce must be aware of and

understand the rules.

Any complex organization must have processes and rules to con-Any complex organization must have processes and rules to con-Any complex organization must have processes and rules to con-Any complex organization must have processes and rules to con-Any complex organization must have processes and rules to con-Any complex organization must have processes and rules to con-Any complex organization must have processes and rules to con-Any complex organization must have processes and rules to con-Any complex organization must have processes and rules to con-Any complex organization must have processes and rules to con-Any complex organization must have processes and rules to con-Any complex organization must have processes and rules to con-Any complex organization must have processes and rules to con-duct its business. NASA is no exception. In a complex govern-duct its business. NASA is no exception. In a complex govern-duct its business. NASA is no exception. In a complex govern-duct its business. NASA is no exception. In a complex govern-duct its business. NASA is no exception. In a complex govern-duct its business. NASA is no exception. In a complex govern-duct its business. NASA is no exception. In a complex govern-duct its business. NASA is no exception. In a complex govern-duct its business. NASA is no exception. In a complex govern-duct its business. NASA is no exception. In a complex govern-duct its business. NASA is no exception. In a complex govern-duct its business. NASA is no exception. In a complex govern-ment organization such as NASA, many policies, requirements, ment organization such as NASA, many policies, requirements, ment organization such as NASA, many policies, requirements, ment organization such as NASA, many policies, requirements, ment organization such as NASA, many policies, requirements, ment organization such as NASA, many policies, requirements, ment organization such as NASA, many policies, requirements, ment organization such as NASA, many policies, requirements, ment organization such as NASA, many policies, requirements, ment organization such as NASA, many policies, requirements, ment organization such as NASA, many policies, requirements, ment organization such as NASA, many policies, requirements, ment organization such as NASA, many policies, requirements, and procedures are developed for employees to follow in the and procedures are developed for employees to follow in the and procedures are developed for employees to follow in the and procedures are developed for employees to follow in the and procedures are developed for employees to follow in the and procedures are developed for employees to follow in the and procedures are developed for employees to follow in the and procedures are developed for employees to follow in the and procedures are developed for employees to follow in the and procedures are developed for employees to follow in the and procedures are developed for employees to follow in the and procedures are developed for employees to follow in the conduct of programs, missions, designs, tests, and operations. conduct of programs, missions, designs, tests, and operations. conduct of programs, missions, designs, tests, and operations. conduct of programs, missions, designs, tests, and operations. conduct of programs, missions, designs, tests, and operations. conduct of programs, missions, designs, tests, and operations. conduct of programs, missions, designs, tests, and operations. conduct of programs, missions, designs, tests, and operations. conduct of programs, missions, designs, tests, and operations. conduct of programs, missions, designs, tests, and operations. conduct of programs, missions, designs, tests, and operations. conduct of programs, missions, designs, tests, and operations. Included in this category are the many processes for manag-Included in this category are the many processes for manag-Included in this category are the many processes for manag-Included in this category are the many processes for manag-Included in this category are the many processes for manag-Included in this category are the many processes for manag-Included in this category are the many processes for manag-Included in this category are the many processes for manag-Included in this category are the many processes for manag-Included in this category are the many processes for manag-Included in this category are the many processes for manag-Included in this category are the many processes for manag-ing the external workforce of NASA through its large cadre of ing the external workforce of NASA through its large cadre of ing the external workforce of NASA through its large cadre of ing the external workforce of NASA through its large cadre of ing the external workforce of NASA through its large cadre of ing the external workforce of NASA through its large cadre of ing the external workforce of NASA through its large cadre of ing the external workforce of NASA through its large cadre of ing the external workforce of NASA through its large cadre of ing the external workforce of NASA through its large cadre of ing the external workforce of NASA through its large cadre of ing the external workforce of NASA through its large cadre of contractors. Many of these rules and processes were established contractors. Many of these rules and processes were established contractors. Many of these rules and processes were established contractors. Many of these rules and processes were established contractors. Many of these rules and processes were established contractors. Many of these rules and processes were established contractors. Many of these rules and processes were established contractors. Many of these rules and processes were established contractors. Many of these rules and processes were established contractors. Many of these rules and processes were established contractors. Many of these rules and processes were established contractors. Many of these rules and processes were established contractors. Many of these rules and processes were established as a result of adoption of best practices or lessons learned from as a result of adoption of best practices or lessons learned from as a result of adoption of best practices or lessons learned from as a result of adoption of best practices or lessons learned from as a result of adoption of best practices or lessons learned from as a result of adoption of best practices or lessons learned from as a result of adoption of best practices or lessons learned from as a result of adoption of best practices or lessons learned from as a result of adoption of best practices or lessons learned from as a result of adoption of best practices or lessons learned from as a result of adoption of best practices or lessons learned from as a result of adoption of best practices or lessons learned from program history. Some are the result of informal adoption into program history. Some are the result of informal adoption into program history. Some are the result of informal adoption into program history. Some are the result of informal adoption into program history. Some are the result of informal adoption into program history. Some are the result of informal adoption into program history. Some are the result of informal adoption into program history. Some are the result of informal adoption into program history. Some are the result of informal adoption into program history. Some are the result of informal adoption into program history. Some are the result of informal adoption into program history. Some are the result of informal adoption into program history. Some are the result of informal adoption into the culture of NASA – in essence – how NASA conducts its busi-the culture of NASA – in essence – how NASA conducts its busi-the culture of NASA – in essence – how NASA conducts its busi-the culture of NASA – in essence – how NASA conducts its busi-the culture of NASA – in essence – how NASA conducts its busi-the culture of NASA – in essence – how NASA conducts its busi-the culture of NASA – in essence – how NASA conducts its busi-the culture of NASA – in essence – how NASA conducts its busi-the culture of NASA – in essence – how NASA conducts its busi-the culture of NASA – in essence – how NASA conducts its busi-the culture of NASA – in essence – how NASA conducts its busi-the culture of NASA – in essence – how NASA conducts its busi-ness. Others may be confl icting among organizations, outdated, ness. Others may be confl icting among organizations, outdated, ness. Others may be confl icting among organizations, outdated, ness. Others may be confl icting among organizations, outdated, ness. Others may be confl icting among organizations, outdated, ness. Others may be confl icting among organizations, outdated, ness. Others may be confl icting among organizations, outdated, ness. Others may be confl icting among organizations, outdated, ness. Others may be confl icting among organizations, outdated, ness. Others may be confl icting among organizations, outdated, ness. Others may be confl icting among organizations, outdated, ness. Others may be confl icting among organizations, outdated, ness. Others may be confl icting among organizations, outdated, or merely bureaucratic in nature offering little concrete benefi t. or merely bureaucratic in nature offering little concrete benefi t. or merely bureaucratic in nature offering little concrete benefi t. or merely bureaucratic in nature offering little concrete benefi t. or merely bureaucratic in nature offering little concrete benefi t. or merely bureaucratic in nature offering little concrete benefi t. or merely bureaucratic in nature offering little concrete benefi t. or merely bureaucratic in nature offering little concrete benefi t. or merely bureaucratic in nature offering little concrete benefi t. or merely bureaucratic in nature offering little concrete benefi t. or merely bureaucratic in nature offering little concrete benefi t. or merely bureaucratic in nature offering little concrete benefi t. The CAIB examined NASA̓ s processes and rules closely as it The CAIB examined NASA̓ s processes and rules closely as it The CAIB examined NASA̓ s processes and rules closely as it The CAIB examined NASA̓ s processes and rules closely as it The CAIB examined NASA̓ s processes and rules closely as it The CAIB examined NASA̓ s processes and rules closely as it The CAIB examined NASA̓ s processes and rules closely as it The CAIB examined NASA̓ s processes and rules closely as it The CAIB examined NASA̓ s processes and rules closely as it The CAIB examined NASA̓ s processes and rules closely as it The CAIB examined NASA̓ s processes and rules closely as it The CAIB examined NASA̓ s processes and rules closely as it related to the Shuttle accident and arrived at some key conclu-related to the Shuttle accident and arrived at some key conclu-related to the Shuttle accident and arrived at some key conclu-related to the Shuttle accident and arrived at some key conclu-related to the Shuttle accident and arrived at some key conclu-related to the Shuttle accident and arrived at some key conclu-related to the Shuttle accident and arrived at some key conclu-related to the Shuttle accident and arrived at some key conclu-related to the Shuttle accident and arrived at some key conclu-related to the Shuttle accident and arrived at some key conclu-related to the Shuttle accident and arrived at some key conclu-related to the Shuttle accident and arrived at some key conclu-related to the Shuttle accident and arrived at some key conclu-sions. sions.

Throughout the CAIB Report, a recurring observation was that Throughout the CAIB Report, a recurring observation was that Throughout the CAIB Report, a recurring observation was that Throughout the CAIB Report, a recurring observation was that Throughout the CAIB Report, a recurring observation was that Throughout the CAIB Report, a recurring observation was that Throughout the CAIB Report, a recurring observation was that Throughout the CAIB Report, a recurring observation was that Throughout the CAIB Report, a recurring observation was that Throughout the CAIB Report, a recurring observation was that Throughout the CAIB Report, a recurring observation was that Throughout the CAIB Report, a recurring observation was that NASA did not follow its own rules. The Board discovered orga-NASA did not follow its own rules. The Board discovered orga-NASA did not follow its own rules. The Board discovered orga-NASA did not follow its own rules. The Board discovered orga-NASA did not follow its own rules. The Board discovered orga-NASA did not follow its own rules. The Board discovered orga-NASA did not follow its own rules. The Board discovered orga-NASA did not follow its own rules. The Board discovered orga-NASA did not follow its own rules. The Board discovered orga-NASA did not follow its own rules. The Board discovered orga-NASA did not follow its own rules. The Board discovered orga-NASA did not follow its own rules. The Board discovered orga-NASA did not follow its own rules. The Board discovered orga-nizational practices detrimental to safety and reliability including nizational practices detrimental to safety and reliability including nizational practices detrimental to safety and reliability including nizational practices detrimental to safety and reliability including nizational practices detrimental to safety and reliability including nizational practices detrimental to safety and reliability including nizational practices detrimental to safety and reliability including nizational practices detrimental to safety and reliability including nizational practices detrimental to safety and reliability including nizational practices detrimental to safety and reliability including nizational practices detrimental to safety and reliability including nizational practices detrimental to safety and reliability including the “evolution of an informal chain of command and decision-the “evolution of an informal chain of command and decision-the “evolution of an informal chain of command and decision-the “evolution of an informal chain of command and decision-the “evolution of an informal chain of command and decision-the “evolution of an informal chain of command and decision-the “evolution of an informal chain of command and decision-the “evolution of an informal chain of command and decision-the “evolution of an informal chain of command and decision-the “evolution of an informal chain of command and decision-the “evolution of an informal chain of command and decision-the “evolution of an informal chain of command and decision-making processes that operated outside the organizationʼs rules.” making processes that operated outside the organizationʼs rules.” making processes that operated outside the organizationʼs rules.” making processes that operated outside the organizationʼs rules.” making processes that operated outside the organizationʼs rules.” making processes that operated outside the organizationʼs rules.” making processes that operated outside the organizationʼs rules.” making processes that operated outside the organizationʼs rules.” making processes that operated outside the organizationʼs rules.” making processes that operated outside the organizationʼs rules.” making processes that operated outside the organizationʼs rules.” making processes that operated outside the organizationʼs rules.” Yet, the Board believed rules which were followed within NASA Yet, the Board believed rules which were followed within NASA Yet, the Board believed rules which were followed within NASA Yet, the Board believed rules which were followed within NASA Yet, the Board believed rules which were followed within NASA Yet, the Board believed rules which were followed within NASA Yet, the Board believed rules which were followed within NASA Yet, the Board believed rules which were followed within NASA Yet, the Board believed rules which were followed within NASA Yet, the Board believed rules which were followed within NASA Yet, the Board believed rules which were followed within NASA Yet, the Board believed rules which were followed within NASA were often more bureaucratic and had the effect of stifl ing critical were often more bureaucratic and had the effect of stifl ing critical were often more bureaucratic and had the effect of stifl ing critical were often more bureaucratic and had the effect of stifl ing critical were often more bureaucratic and had the effect of stifl ing critical were often more bureaucratic and had the effect of stifl ing critical were often more bureaucratic and had the effect of stifl ing critical were often more bureaucratic and had the effect of stifl ing critical were often more bureaucratic and had the effect of stifl ing critical were often more bureaucratic and had the effect of stifl ing critical were often more bureaucratic and had the effect of stifl ing critical were often more bureaucratic and had the effect of stifl ing critical were often more bureaucratic and had the effect of stifl ing critical communication. communication. communication. communication.

After evaluating the CAIB Report and the Safety and Mission After evaluating the CAIB Report and the Safety and Mission After evaluating the CAIB Report and the Safety and Mission After evaluating the CAIB Report and the Safety and Mission After evaluating the CAIB Report and the Safety and Mission After evaluating the CAIB Report and the Safety and Mission After evaluating the CAIB Report and the Safety and Mission After evaluating the CAIB Report and the Safety and Mission After evaluating the CAIB Report and the Safety and Mission After evaluating the CAIB Report and the Safety and Mission After evaluating the CAIB Report and the Safety and Mission After evaluating the CAIB Report and the Safety and Mission Success Week feedback, the Diaz Team has concluded that many Success Week feedback, the Diaz Team has concluded that many Success Week feedback, the Diaz Team has concluded that many Success Week feedback, the Diaz Team has concluded that many Success Week feedback, the Diaz Team has concluded that many Success Week feedback, the Diaz Team has concluded that many Success Week feedback, the Diaz Team has concluded that many Success Week feedback, the Diaz Team has concluded that many Success Week feedback, the Diaz Team has concluded that many Success Week feedback, the Diaz Team has concluded that many Success Week feedback, the Diaz Team has concluded that many Success Week feedback, the Diaz Team has concluded that many Success Week feedback, the Diaz Team has concluded that many in the workforce do not understand the policies and rules they are in the workforce do not understand the policies and rules they are in the workforce do not understand the policies and rules they are in the workforce do not understand the policies and rules they are in the workforce do not understand the policies and rules they are in the workforce do not understand the policies and rules they are in the workforce do not understand the policies and rules they are in the workforce do not understand the policies and rules they are in the workforce do not understand the policies and rules they are in the workforce do not understand the policies and rules they are in the workforce do not understand the policies and rules they are in the workforce do not understand the policies and rules they are required to adhere to. required to adhere to. required to adhere to. required to adhere to. required to adhere to.

The CAIB Report had this to say about rules:The CAIB Report had this to say about rules:The CAIB Report had this to say about rules:The CAIB Report had this to say about rules:The CAIB Report had this to say about rules:The CAIB Report had this to say about rules:The CAIB Report had this to say about rules:The CAIB Report had this to say about rules:The CAIB Report had this to say about rules:The CAIB Report had this to say about rules:

Cultural traits and organizational practices detrimental Cultural traits and organizational practices detrimental Cultural traits and organizational practices detrimental Cultural traits and organizational practices detrimental Cultural traits and organizational practices detrimental Cultural traits and organizational practices detrimental Cultural traits and organizational practices detrimental Cultural traits and organizational practices detrimental Cultural traits and organizational practices detrimental Cultural traits and organizational practices detrimental Cultural traits and organizational practices detrimental to safety were allowed to develop, including... lack of to safety were allowed to develop, including... lack of to safety were allowed to develop, including... lack of to safety were allowed to develop, including... lack of to safety were allowed to develop, including... lack of to safety were allowed to develop, including... lack of to safety were allowed to develop, including... lack of to safety were allowed to develop, including... lack of to safety were allowed to develop, including... lack of to safety were allowed to develop, including... lack of integrated management across program elements... and integrated management across program elements... and integrated management across program elements... and integrated management across program elements... and integrated management across program elements... and integrated management across program elements... and integrated management across program elements... and integrated management across program elements... and integrated management across program elements... and integrated management across program elements... and integrated management across program elements... and the evolution of an informal chain of command and deci-the evolution of an informal chain of command and deci-the evolution of an informal chain of command and deci-the evolution of an informal chain of command and deci-the evolution of an informal chain of command and deci-the evolution of an informal chain of command and deci-the evolution of an informal chain of command and deci-the evolution of an informal chain of command and deci-the evolution of an informal chain of command and deci-the evolution of an informal chain of command and deci-sion-making processes that operated outside the organi-sion-making processes that operated outside the organi-sion-making processes that operated outside the organi-sion-making processes that operated outside the organi-sion-making processes that operated outside the organi-sion-making processes that operated outside the organi-sion-making processes that operated outside the organi-sion-making processes that operated outside the organi-sion-making processes that operated outside the organi-sion-making processes that operated outside the organi-sion-making processes that operated outside the organi-zation’s rules. (CAIB, Executive Summary, p. 9)zation’s rules. (CAIB, Executive Summary, p. 9)zation’s rules. (CAIB, Executive Summary, p. 9)zation’s rules. (CAIB, Executive Summary, p. 9)zation’s rules. (CAIB, Executive Summary, p. 9)zation’s rules. (CAIB, Executive Summary, p. 9)zation’s rules. (CAIB, Executive Summary, p. 9)zation’s rules. (CAIB, Executive Summary, p. 9)zation’s rules. (CAIB, Executive Summary, p. 9)

The way in which NASA develops and executes its rules and The way in which NASA develops and executes its rules and The way in which NASA develops and executes its rules and The way in which NASA develops and executes its rules and The way in which NASA develops and executes its rules and The way in which NASA develops and executes its rules and The way in which NASA develops and executes its rules and The way in which NASA develops and executes its rules and The way in which NASA develops and executes its rules and The way in which NASA develops and executes its rules and The way in which NASA develops and executes its rules and The way in which NASA develops and executes its rules and The way in which NASA develops and executes its rules and processes embodies a fundamental cultural trait for the Agency. processes embodies a fundamental cultural trait for the Agency. processes embodies a fundamental cultural trait for the Agency. processes embodies a fundamental cultural trait for the Agency. processes embodies a fundamental cultural trait for the Agency. processes embodies a fundamental cultural trait for the Agency. processes embodies a fundamental cultural trait for the Agency. processes embodies a fundamental cultural trait for the Agency. processes embodies a fundamental cultural trait for the Agency. processes embodies a fundamental cultural trait for the Agency. processes embodies a fundamental cultural trait for the Agency. processes embodies a fundamental cultural trait for the Agency. Organizations that deal with high-risk technology must develop Organizations that deal with high-risk technology must develop Organizations that deal with high-risk technology must develop Organizations that deal with high-risk technology must develop Organizations that deal with high-risk technology must develop Organizations that deal with high-risk technology must develop Organizations that deal with high-risk technology must develop Organizations that deal with high-risk technology must develop Organizations that deal with high-risk technology must develop Organizations that deal with high-risk technology must develop Organizations that deal with high-risk technology must develop Organizations that deal with high-risk technology must develop Organizations that deal with high-risk technology must develop a best practices culture in order to operate safely and reliably. To a best practices culture in order to operate safely and reliably. To a best practices culture in order to operate safely and reliably. To a best practices culture in order to operate safely and reliably. To a best practices culture in order to operate safely and reliably. To a best practices culture in order to operate safely and reliably. To a best practices culture in order to operate safely and reliably. To a best practices culture in order to operate safely and reliably. To a best practices culture in order to operate safely and reliably. To a best practices culture in order to operate safely and reliably. To a best practices culture in order to operate safely and reliably. To a best practices culture in order to operate safely and reliably. To achieve this within NASA, all programs must develop rules that achieve this within NASA, all programs must develop rules that achieve this within NASA, all programs must develop rules that achieve this within NASA, all programs must develop rules that achieve this within NASA, all programs must develop rules that achieve this within NASA, all programs must develop rules that achieve this within NASA, all programs must develop rules that achieve this within NASA, all programs must develop rules that achieve this within NASA, all programs must develop rules that achieve this within NASA, all programs must develop rules that achieve this within NASA, all programs must develop rules that achieve this within NASA, all programs must develop rules that achieve this within NASA, all programs must develop rules that lead to increased communication and enhanced decision-mak-lead to increased communication and enhanced decision-mak-lead to increased communication and enhanced decision-mak-lead to increased communication and enhanced decision-mak-lead to increased communication and enhanced decision-mak-lead to increased communication and enhanced decision-mak-lead to increased communication and enhanced decision-mak-lead to increased communication and enhanced decision-mak-lead to increased communication and enhanced decision-mak-lead to increased communication and enhanced decision-mak-lead to increased communication and enhanced decision-mak-lead to increased communication and enhanced decision-mak-ing.ing.

The observations and fi ndings of the CAIB also revealed a need The observations and fi ndings of the CAIB also revealed a need The observations and fi ndings of the CAIB also revealed a need The observations and fi ndings of the CAIB also revealed a need The observations and fi ndings of the CAIB also revealed a need The observations and fi ndings of the CAIB also revealed a need The observations and fi ndings of the CAIB also revealed a need The observations and fi ndings of the CAIB also revealed a need The observations and fi ndings of the CAIB also revealed a need The observations and fi ndings of the CAIB also revealed a need The observations and fi ndings of the CAIB also revealed a need The observations and fi ndings of the CAIB also revealed a need for NASA to examine its processes, make changes where appro-for NASA to examine its processes, make changes where appro-for NASA to examine its processes, make changes where appro-for NASA to examine its processes, make changes where appro-for NASA to examine its processes, make changes where appro-for NASA to examine its processes, make changes where appro-for NASA to examine its processes, make changes where appro-for NASA to examine its processes, make changes where appro-for NASA to examine its processes, make changes where appro-for NASA to examine its processes, make changes where appro-for NASA to examine its processes, make changes where appro-for NASA to examine its processes, make changes where appro-for NASA to examine its processes, make changes where appro-priate, and apply the processes uniformly across programs. The priate, and apply the processes uniformly across programs. The priate, and apply the processes uniformly across programs. The priate, and apply the processes uniformly across programs. The priate, and apply the processes uniformly across programs. The priate, and apply the processes uniformly across programs. The priate, and apply the processes uniformly across programs. The priate, and apply the processes uniformly across programs. The priate, and apply the processes uniformly across programs. The priate, and apply the processes uniformly across programs. The priate, and apply the processes uniformly across programs. The priate, and apply the processes uniformly across programs. The Board, in essence, stated that NASA must set required processes Board, in essence, stated that NASA must set required processes Board, in essence, stated that NASA must set required processes Board, in essence, stated that NASA must set required processes Board, in essence, stated that NASA must set required processes Board, in essence, stated that NASA must set required processes Board, in essence, stated that NASA must set required processes Board, in essence, stated that NASA must set required processes Board, in essence, stated that NASA must set required processes Board, in essence, stated that NASA must set required processes Board, in essence, stated that NASA must set required processes Board, in essence, stated that NASA must set required processes Board, in essence, stated that NASA must set required processes that ensure accurate and timely information fl ow and then “fol-that ensure accurate and timely information fl ow and then “fol-that ensure accurate and timely information fl ow and then “fol-that ensure accurate and timely information fl ow and then “fol-that ensure accurate and timely information fl ow and then “fol-that ensure accurate and timely information fl ow and then “fol-that ensure accurate and timely information fl ow and then “fol-that ensure accurate and timely information fl ow and then “fol-that ensure accurate and timely information fl ow and then “fol-that ensure accurate and timely information fl ow and then “fol-that ensure accurate and timely information fl ow and then “fol-that ensure accurate and timely information fl ow and then “fol-low the rules” established for making decisions with this data. low the rules” established for making decisions with this data. low the rules” established for making decisions with this data. low the rules” established for making decisions with this data. low the rules” established for making decisions with this data. low the rules” established for making decisions with this data. low the rules” established for making decisions with this data. low the rules” established for making decisions with this data. low the rules” established for making decisions with this data. low the rules” established for making decisions with this data. low the rules” established for making decisions with this data. low the rules” established for making decisions with this data. low the rules” established for making decisions with this data. While many of the 40 actions in the Diaz Team Matrix require While many of the 40 actions in the Diaz Team Matrix require While many of the 40 actions in the Diaz Team Matrix require While many of the 40 actions in the Diaz Team Matrix require While many of the 40 actions in the Diaz Team Matrix require While many of the 40 actions in the Diaz Team Matrix require While many of the 40 actions in the Diaz Team Matrix require While many of the 40 actions in the Diaz Team Matrix require While many of the 40 actions in the Diaz Team Matrix require While many of the 40 actions in the Diaz Team Matrix require While many of the 40 actions in the Diaz Team Matrix require While many of the 40 actions in the Diaz Team Matrix require that the policies governing the R-O-F area be reviewed and mod-that the policies governing the R-O-F area be reviewed and mod-that the policies governing the R-O-F area be reviewed and mod-that the policies governing the R-O-F area be reviewed and mod-that the policies governing the R-O-F area be reviewed and mod-that the policies governing the R-O-F area be reviewed and mod-that the policies governing the R-O-F area be reviewed and mod-that the policies governing the R-O-F area be reviewed and mod-that the policies governing the R-O-F area be reviewed and mod-that the policies governing the R-O-F area be reviewed and mod-that the policies governing the R-O-F area be reviewed and mod-that the policies governing the R-O-F area be reviewed and mod-ifi ed if necessary, a complete review of policies and directives in ifi ed if necessary, a complete review of policies and directives in ifi ed if necessary, a complete review of policies and directives in ifi ed if necessary, a complete review of policies and directives in ifi ed if necessary, a complete review of policies and directives in ifi ed if necessary, a complete review of policies and directives in ifi ed if necessary, a complete review of policies and directives in ifi ed if necessary, a complete review of policies and directives in ifi ed if necessary, a complete review of policies and directives in ifi ed if necessary, a complete review of policies and directives in ifi ed if necessary, a complete review of policies and directives in ifi ed if necessary, a complete review of policies and directives in ifi ed if necessary, a complete review of policies and directives in the Agency should be conducted.the Agency should be conducted.the Agency should be conducted.the Agency should be conducted.the Agency should be conducted.the Agency should be conducted.the Agency should be conducted.

The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced the Diaz Team assessment:the Diaz Team assessment:the Diaz Team assessment:the Diaz Team assessment:the Diaz Team assessment:the Diaz Team assessment:the Diaz Team assessment:

» We say all the right language and have all the right We say all the right language and have all the right We say all the right language and have all the right We say all the right language and have all the right We say all the right language and have all the right We say all the right language and have all the right We say all the right language and have all the right We say all the right language and have all the right We say all the right language and have all the right We say all the right language and have all the right procedures, but donʼt follow them.procedures, but donʼt follow them.procedures, but donʼt follow them.procedures, but donʼt follow them.procedures, but donʼt follow them.procedures, but donʼt follow them.

» When internal and contracted requirements are not When internal and contracted requirements are not When internal and contracted requirements are not When internal and contracted requirements are not When internal and contracted requirements are not When internal and contracted requirements are not When internal and contracted requirements are not When internal and contracted requirements are not When internal and contracted requirements are not fi rmly established, employees can feel that nothing is fi rmly established, employees can feel that nothing is fi rmly established, employees can feel that nothing is fi rmly established, employees can feel that nothing is fi rmly established, employees can feel that nothing is fi rmly established, employees can feel that nothing is fi rmly established, employees can feel that nothing is fi rmly established, employees can feel that nothing is fi rmly established, employees can feel that nothing is fi rmly established, employees can feel that nothing is mandatory. mandatory. mandatory.

»» Crew Resource Management is a process used in other Crew Resource Management is a process used in other Crew Resource Management is a process used in other Crew Resource Management is a process used in other Crew Resource Management is a process used in other Crew Resource Management is a process used in other Crew Resource Management is a process used in other Crew Resource Management is a process used in other Crew Resource Management is a process used in other Crew Resource Management is a process used in other Crew Resource Management is a process used in other industries that can be applied across NASA and in industries that can be applied across NASA and in industries that can be applied across NASA and in industries that can be applied across NASA and in industries that can be applied across NASA and in industries that can be applied across NASA and in industries that can be applied across NASA and in industries that can be applied across NASA and in industries that can be applied across NASA and in particular mission-critical management positions. particular mission-critical management positions. particular mission-critical management positions. particular mission-critical management positions. particular mission-critical management positions. particular mission-critical management positions. particular mission-critical management positions. particular mission-critical management positions. particular mission-critical management positions. particular mission-critical management positions.

In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address each R-O-F, the Diaz Team has one goal addressing the Pro-each R-O-F, the Diaz Team has one goal addressing the Pro-each R-O-F, the Diaz Team has one goal addressing the Pro-each R-O-F, the Diaz Team has one goal addressing the Pro-each R-O-F, the Diaz Team has one goal addressing the Pro-each R-O-F, the Diaz Team has one goal addressing the Pro-each R-O-F, the Diaz Team has one goal addressing the Pro-each R-O-F, the Diaz Team has one goal addressing the Pro-each R-O-F, the Diaz Team has one goal addressing the Pro-each R-O-F, the Diaz Team has one goal addressing the Pro-each R-O-F, the Diaz Team has one goal addressing the Pro-each R-O-F, the Diaz Team has one goal addressing the Pro-cesses and Rules category, as shown in Table 5.cesses and Rules category, as shown in Table 5.cesses and Rules category, as shown in Table 5.cesses and Rules category, as shown in Table 5.cesses and Rules category, as shown in Table 5.cesses and Rules category, as shown in Table 5.cesses and Rules category, as shown in Table 5.cesses and Rules category, as shown in Table 5.cesses and Rules category, as shown in Table 5.

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

Processes and Rules – Diaz Team Goal

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

1 41 4

1.6 TECHNICAL CAPABILITIES

CAIB Report Chapter 7, p179:As a result [of the Space Flight Operations Contract], experienced engineers changed jobs, NASA grew de-pendent on contractors for technical support, contract monitoring requirements increased, and positions were subsequently staffed by less experienced engineers who were placed in management roles. Collectively, this eroded NASA’s in-house engineering and technical capabilities.

NASA’s in-house capabilities and expertise have eroded.

Agency-wide Themes• Analytical models and simulation tools must be

used appropriately.• NASA must address the loss of technical exper-

tise due to retirement and outsourcing.• Advanced technical capabilities must be

developed.

NASA has always viewed itself as a cutting-edge technology NASA has always viewed itself as a cutting-edge technology NASA has always viewed itself as a cutting-edge technology NASA has always viewed itself as a cutting-edge technology NASA has always viewed itself as a cutting-edge technology NASA has always viewed itself as a cutting-edge technology NASA has always viewed itself as a cutting-edge technology NASA has always viewed itself as a cutting-edge technology NASA has always viewed itself as a cutting-edge technology NASA has always viewed itself as a cutting-edge technology NASA has always viewed itself as a cutting-edge technology NASA has always viewed itself as a cutting-edge technology organization, with accomplished scientists and engineers devel-organization, with accomplished scientists and engineers devel-organization, with accomplished scientists and engineers devel-organization, with accomplished scientists and engineers devel-organization, with accomplished scientists and engineers devel-organization, with accomplished scientists and engineers devel-organization, with accomplished scientists and engineers devel-organization, with accomplished scientists and engineers devel-organization, with accomplished scientists and engineers devel-organization, with accomplished scientists and engineers devel-organization, with accomplished scientists and engineers devel-organization, with accomplished scientists and engineers devel-organization, with accomplished scientists and engineers devel-oping and applying the most modern of technology tools. During oping and applying the most modern of technology tools. During oping and applying the most modern of technology tools. During oping and applying the most modern of technology tools. During oping and applying the most modern of technology tools. During oping and applying the most modern of technology tools. During oping and applying the most modern of technology tools. During oping and applying the most modern of technology tools. During oping and applying the most modern of technology tools. During oping and applying the most modern of technology tools. During oping and applying the most modern of technology tools. During oping and applying the most modern of technology tools. During the investigation of the the investigation of the the investigation of the the investigation of the the investigation of the ColumbiaColumbiaColumbia accident, the CAIB came to accident, the CAIB came to accident, the CAIB came to accident, the CAIB came to accident, the CAIB came to accident, the CAIB came to believe otherwise. There was evidence of erosion in NASA̓ s believe otherwise. There was evidence of erosion in NASA̓ s believe otherwise. There was evidence of erosion in NASA̓ s believe otherwise. There was evidence of erosion in NASA̓ s believe otherwise. There was evidence of erosion in NASA̓ s believe otherwise. There was evidence of erosion in NASA̓ s believe otherwise. There was evidence of erosion in NASA̓ s believe otherwise. There was evidence of erosion in NASA̓ s believe otherwise. There was evidence of erosion in NASA̓ s believe otherwise. There was evidence of erosion in NASA̓ s believe otherwise. There was evidence of erosion in NASA̓ s believe otherwise. There was evidence of erosion in NASA̓ s technological capabilities and expertise within the Shuttle Pro-technological capabilities and expertise within the Shuttle Pro-technological capabilities and expertise within the Shuttle Pro-technological capabilities and expertise within the Shuttle Pro-technological capabilities and expertise within the Shuttle Pro-technological capabilities and expertise within the Shuttle Pro-technological capabilities and expertise within the Shuttle Pro-technological capabilities and expertise within the Shuttle Pro-technological capabilities and expertise within the Shuttle Pro-technological capabilities and expertise within the Shuttle Pro-technological capabilities and expertise within the Shuttle Pro-technological capabilities and expertise within the Shuttle Pro-gram. The CAIB found problems with the use of modern tools gram. The CAIB found problems with the use of modern tools gram. The CAIB found problems with the use of modern tools gram. The CAIB found problems with the use of modern tools gram. The CAIB found problems with the use of modern tools gram. The CAIB found problems with the use of modern tools gram. The CAIB found problems with the use of modern tools gram. The CAIB found problems with the use of modern tools gram. The CAIB found problems with the use of modern tools gram. The CAIB found problems with the use of modern tools gram. The CAIB found problems with the use of modern tools gram. The CAIB found problems with the use of modern tools gram. The CAIB found problems with the use of modern tools and methods for information management. Research organiza-and methods for information management. Research organiza-and methods for information management. Research organiza-and methods for information management. Research organiza-and methods for information management. Research organiza-and methods for information management. Research organiza-and methods for information management. Research organiza-and methods for information management. Research organiza-and methods for information management. Research organiza-and methods for information management. Research organiza-and methods for information management. Research organiza-and methods for information management. Research organiza-tions today rely on modeling, simulation, design, and analytical tions today rely on modeling, simulation, design, and analytical tions today rely on modeling, simulation, design, and analytical tions today rely on modeling, simulation, design, and analytical tions today rely on modeling, simulation, design, and analytical tions today rely on modeling, simulation, design, and analytical tions today rely on modeling, simulation, design, and analytical tions today rely on modeling, simulation, design, and analytical tions today rely on modeling, simulation, design, and analytical tions today rely on modeling, simulation, design, and analytical tions today rely on modeling, simulation, design, and analytical tions today rely on modeling, simulation, design, and analytical tions today rely on modeling, simulation, design, and analytical tools. At NASA, the CAIB found ineffective and inconsistent ac-tools. At NASA, the CAIB found ineffective and inconsistent ac-tools. At NASA, the CAIB found ineffective and inconsistent ac-tools. At NASA, the CAIB found ineffective and inconsistent ac-tools. At NASA, the CAIB found ineffective and inconsistent ac-tools. At NASA, the CAIB found ineffective and inconsistent ac-tools. At NASA, the CAIB found ineffective and inconsistent ac-tools. At NASA, the CAIB found ineffective and inconsistent ac-tools. At NASA, the CAIB found ineffective and inconsistent ac-tools. At NASA, the CAIB found ineffective and inconsistent ac-tools. At NASA, the CAIB found ineffective and inconsistent ac-tools. At NASA, the CAIB found ineffective and inconsistent ac-cess to these tools, along with cases of outright misuse. Some of cess to these tools, along with cases of outright misuse. Some of cess to these tools, along with cases of outright misuse. Some of cess to these tools, along with cases of outright misuse. Some of cess to these tools, along with cases of outright misuse. Some of cess to these tools, along with cases of outright misuse. Some of cess to these tools, along with cases of outright misuse. Some of cess to these tools, along with cases of outright misuse. Some of cess to these tools, along with cases of outright misuse. Some of cess to these tools, along with cases of outright misuse. Some of cess to these tools, along with cases of outright misuse. Some of cess to these tools, along with cases of outright misuse. Some of cess to these tools, along with cases of outright misuse. Some of this stemmed from a lack of technical understanding. The CAIB this stemmed from a lack of technical understanding. The CAIB this stemmed from a lack of technical understanding. The CAIB this stemmed from a lack of technical understanding. The CAIB this stemmed from a lack of technical understanding. The CAIB this stemmed from a lack of technical understanding. The CAIB this stemmed from a lack of technical understanding. The CAIB this stemmed from a lack of technical understanding. The CAIB this stemmed from a lack of technical understanding. The CAIB this stemmed from a lack of technical understanding. The CAIB this stemmed from a lack of technical understanding. The CAIB this stemmed from a lack of technical understanding. The CAIB Report stated it this way:Report stated it this way:Report stated it this way:Report stated it this way:Report stated it this way:

As a result [of the Space Flight Operations Contract], As a result [of the Space Flight Operations Contract], As a result [of the Space Flight Operations Contract], As a result [of the Space Flight Operations Contract], As a result [of the Space Flight Operations Contract], As a result [of the Space Flight Operations Contract], As a result [of the Space Flight Operations Contract], As a result [of the Space Flight Operations Contract], As a result [of the Space Flight Operations Contract], As a result [of the Space Flight Operations Contract], experienced engineers changed jobs, NASA grew de-experienced engineers changed jobs, NASA grew de-experienced engineers changed jobs, NASA grew de-experienced engineers changed jobs, NASA grew de-experienced engineers changed jobs, NASA grew de-experienced engineers changed jobs, NASA grew de-experienced engineers changed jobs, NASA grew de-experienced engineers changed jobs, NASA grew de-experienced engineers changed jobs, NASA grew de-experienced engineers changed jobs, NASA grew de-experienced engineers changed jobs, NASA grew de-pendent on contractors for technical support, contract pendent on contractors for technical support, contract pendent on contractors for technical support, contract pendent on contractors for technical support, contract pendent on contractors for technical support, contract pendent on contractors for technical support, contract pendent on contractors for technical support, contract pendent on contractors for technical support, contract pendent on contractors for technical support, contract pendent on contractors for technical support, contract monitoring requirements increased, and positions were monitoring requirements increased, and positions were monitoring requirements increased, and positions were monitoring requirements increased, and positions were monitoring requirements increased, and positions were monitoring requirements increased, and positions were monitoring requirements increased, and positions were monitoring requirements increased, and positions were monitoring requirements increased, and positions were monitoring requirements increased, and positions were monitoring requirements increased, and positions were subsequently staffed by less experienced engineers subsequently staffed by less experienced engineers subsequently staffed by less experienced engineers subsequently staffed by less experienced engineers subsequently staffed by less experienced engineers subsequently staffed by less experienced engineers subsequently staffed by less experienced engineers subsequently staffed by less experienced engineers subsequently staffed by less experienced engineers subsequently staffed by less experienced engineers who were placed in management roles. Collectively, this who were placed in management roles. Collectively, this who were placed in management roles. Collectively, this who were placed in management roles. Collectively, this who were placed in management roles. Collectively, this who were placed in management roles. Collectively, this who were placed in management roles. Collectively, this who were placed in management roles. Collectively, this who were placed in management roles. Collectively, this who were placed in management roles. Collectively, this who were placed in management roles. Collectively, this eroded NASA’s in-house engineering and technical capa-eroded NASA’s in-house engineering and technical capa-eroded NASA’s in-house engineering and technical capa-eroded NASA’s in-house engineering and technical capa-eroded NASA’s in-house engineering and technical capa-eroded NASA’s in-house engineering and technical capa-eroded NASA’s in-house engineering and technical capa-eroded NASA’s in-house engineering and technical capa-eroded NASA’s in-house engineering and technical capa-eroded NASA’s in-house engineering and technical capa-bilities.... (CAIB Report, Chapter 7, p. 179)bilities.... (CAIB Report, Chapter 7, p. 179)bilities.... (CAIB Report, Chapter 7, p. 179)bilities.... (CAIB Report, Chapter 7, p. 179)bilities.... (CAIB Report, Chapter 7, p. 179)bilities.... (CAIB Report, Chapter 7, p. 179)bilities.... (CAIB Report, Chapter 7, p. 179)bilities.... (CAIB Report, Chapter 7, p. 179)

Due to limited resources and current Agency operation philoso-Due to limited resources and current Agency operation philoso-Due to limited resources and current Agency operation philoso-Due to limited resources and current Agency operation philoso-Due to limited resources and current Agency operation philoso-Due to limited resources and current Agency operation philoso-Due to limited resources and current Agency operation philoso-Due to limited resources and current Agency operation philoso-Due to limited resources and current Agency operation philoso-Due to limited resources and current Agency operation philoso-Due to limited resources and current Agency operation philoso-Due to limited resources and current Agency operation philoso-phies, NASA has come to rely on contractors to perform engi-phies, NASA has come to rely on contractors to perform engi-phies, NASA has come to rely on contractors to perform engi-phies, NASA has come to rely on contractors to perform engi-phies, NASA has come to rely on contractors to perform engi-phies, NASA has come to rely on contractors to perform engi-phies, NASA has come to rely on contractors to perform engi-phies, NASA has come to rely on contractors to perform engi-phies, NASA has come to rely on contractors to perform engi-phies, NASA has come to rely on contractors to perform engi-phies, NASA has come to rely on contractors to perform engi-phies, NASA has come to rely on contractors to perform engi-phies, NASA has come to rely on contractors to perform engi-neering functions on its projects. In addition, downsizing without neering functions on its projects. In addition, downsizing without neering functions on its projects. In addition, downsizing without neering functions on its projects. In addition, downsizing without neering functions on its projects. In addition, downsizing without neering functions on its projects. In addition, downsizing without neering functions on its projects. In addition, downsizing without neering functions on its projects. In addition, downsizing without neering functions on its projects. In addition, downsizing without neering functions on its projects. In addition, downsizing without neering functions on its projects. In addition, downsizing without neering functions on its projects. In addition, downsizing without replenishment of critical skills over the past decade has further replenishment of critical skills over the past decade has further replenishment of critical skills over the past decade has further replenishment of critical skills over the past decade has further replenishment of critical skills over the past decade has further replenishment of critical skills over the past decade has further replenishment of critical skills over the past decade has further replenishment of critical skills over the past decade has further replenishment of critical skills over the past decade has further replenishment of critical skills over the past decade has further replenishment of critical skills over the past decade has further replenishment of critical skills over the past decade has further replenishment of critical skills over the past decade has further contributed to a skill imbalance that is liable to be exacerbated contributed to a skill imbalance that is liable to be exacerbated contributed to a skill imbalance that is liable to be exacerbated contributed to a skill imbalance that is liable to be exacerbated contributed to a skill imbalance that is liable to be exacerbated contributed to a skill imbalance that is liable to be exacerbated contributed to a skill imbalance that is liable to be exacerbated contributed to a skill imbalance that is liable to be exacerbated contributed to a skill imbalance that is liable to be exacerbated contributed to a skill imbalance that is liable to be exacerbated contributed to a skill imbalance that is liable to be exacerbated contributed to a skill imbalance that is liable to be exacerbated by future retirements. The above conditions, occurring across the by future retirements. The above conditions, occurring across the by future retirements. The above conditions, occurring across the by future retirements. The above conditions, occurring across the by future retirements. The above conditions, occurring across the by future retirements. The above conditions, occurring across the by future retirements. The above conditions, occurring across the by future retirements. The above conditions, occurring across the by future retirements. The above conditions, occurring across the by future retirements. The above conditions, occurring across the by future retirements. The above conditions, occurring across the by future retirements. The above conditions, occurring across the entire Agency, has resulted in a decline in NASA̓ s technical ca-entire Agency, has resulted in a decline in NASA̓ s technical ca-entire Agency, has resulted in a decline in NASA̓ s technical ca-entire Agency, has resulted in a decline in NASA̓ s technical ca-entire Agency, has resulted in a decline in NASA̓ s technical ca-entire Agency, has resulted in a decline in NASA̓ s technical ca-entire Agency, has resulted in a decline in NASA̓ s technical ca-entire Agency, has resulted in a decline in NASA̓ s technical ca-entire Agency, has resulted in a decline in NASA̓ s technical ca-entire Agency, has resulted in a decline in NASA̓ s technical ca-entire Agency, has resulted in a decline in NASA̓ s technical ca-entire Agency, has resulted in a decline in NASA̓ s technical ca-pabilities and competencies in its civil service workforce, and the pabilities and competencies in its civil service workforce, and the pabilities and competencies in its civil service workforce, and the pabilities and competencies in its civil service workforce, and the pabilities and competencies in its civil service workforce, and the pabilities and competencies in its civil service workforce, and the pabilities and competencies in its civil service workforce, and the pabilities and competencies in its civil service workforce, and the pabilities and competencies in its civil service workforce, and the pabilities and competencies in its civil service workforce, and the pabilities and competencies in its civil service workforce, and the pabilities and competencies in its civil service workforce, and the over-reliance on developmental and operational contractors.over-reliance on developmental and operational contractors.over-reliance on developmental and operational contractors.over-reliance on developmental and operational contractors.over-reliance on developmental and operational contractors.over-reliance on developmental and operational contractors.over-reliance on developmental and operational contractors.over-reliance on developmental and operational contractors.over-reliance on developmental and operational contractors.over-reliance on developmental and operational contractors.over-reliance on developmental and operational contractors.over-reliance on developmental and operational contractors.

The theme of the two CAIB recommendations related to tech-The theme of the two CAIB recommendations related to tech-The theme of the two CAIB recommendations related to tech-The theme of the two CAIB recommendations related to tech-The theme of the two CAIB recommendations related to tech-The theme of the two CAIB recommendations related to tech-The theme of the two CAIB recommendations related to tech-The theme of the two CAIB recommendations related to tech-The theme of the two CAIB recommendations related to tech-The theme of the two CAIB recommendations related to tech-The theme of the two CAIB recommendations related to tech-The theme of the two CAIB recommendations related to tech-nical capabilities implies the Agency-wide need for technical nical capabilities implies the Agency-wide need for technical nical capabilities implies the Agency-wide need for technical nical capabilities implies the Agency-wide need for technical nical capabilities implies the Agency-wide need for technical nical capabilities implies the Agency-wide need for technical nical capabilities implies the Agency-wide need for technical nical capabilities implies the Agency-wide need for technical nical capabilities implies the Agency-wide need for technical nical capabilities implies the Agency-wide need for technical nical capabilities implies the Agency-wide need for technical capacity to maintain documentation and databases and the need capacity to maintain documentation and databases and the need capacity to maintain documentation and databases and the need capacity to maintain documentation and databases and the need capacity to maintain documentation and databases and the need capacity to maintain documentation and databases and the need capacity to maintain documentation and databases and the need capacity to maintain documentation and databases and the need capacity to maintain documentation and databases and the need capacity to maintain documentation and databases and the need capacity to maintain documentation and databases and the need capacity to maintain documentation and databases and the need to implement knowledge management practices and capabilities to implement knowledge management practices and capabilities to implement knowledge management practices and capabilities to implement knowledge management practices and capabilities to implement knowledge management practices and capabilities to implement knowledge management practices and capabilities to implement knowledge management practices and capabilities to implement knowledge management practices and capabilities to implement knowledge management practices and capabilities to implement knowledge management practices and capabilities to implement knowledge management practices and capabilities NASA-wide that are critical to technical management and deci-NASA-wide that are critical to technical management and deci-NASA-wide that are critical to technical management and deci-NASA-wide that are critical to technical management and deci-NASA-wide that are critical to technical management and deci-NASA-wide that are critical to technical management and deci-NASA-wide that are critical to technical management and deci-NASA-wide that are critical to technical management and deci-NASA-wide that are critical to technical management and deci-NASA-wide that are critical to technical management and deci-NASA-wide that are critical to technical management and deci-NASA-wide that are critical to technical management and deci-sion-making. When evaluated from an Agency-wide perspective, sion-making. When evaluated from an Agency-wide perspective, sion-making. When evaluated from an Agency-wide perspective, sion-making. When evaluated from an Agency-wide perspective, sion-making. When evaluated from an Agency-wide perspective, sion-making. When evaluated from an Agency-wide perspective, sion-making. When evaluated from an Agency-wide perspective, sion-making. When evaluated from an Agency-wide perspective, sion-making. When evaluated from an Agency-wide perspective, sion-making. When evaluated from an Agency-wide perspective, sion-making. When evaluated from an Agency-wide perspective, it is clear that all NASA programs need validated models and an-it is clear that all NASA programs need validated models and an-it is clear that all NASA programs need validated models and an-it is clear that all NASA programs need validated models and an-it is clear that all NASA programs need validated models and an-it is clear that all NASA programs need validated models and an-it is clear that all NASA programs need validated models and an-it is clear that all NASA programs need validated models and an-it is clear that all NASA programs need validated models and an-it is clear that all NASA programs need validated models and an-it is clear that all NASA programs need validated models and an-it is clear that all NASA programs need validated models and an-alytical tools to assess the state of their systems and components. alytical tools to assess the state of their systems and components. alytical tools to assess the state of their systems and components. alytical tools to assess the state of their systems and components. alytical tools to assess the state of their systems and components. alytical tools to assess the state of their systems and components. alytical tools to assess the state of their systems and components. alytical tools to assess the state of their systems and components. alytical tools to assess the state of their systems and components. alytical tools to assess the state of their systems and components. alytical tools to assess the state of their systems and components. This will enable enhanced decision-making. Moreover, this im-This will enable enhanced decision-making. Moreover, this im-This will enable enhanced decision-making. Moreover, this im-This will enable enhanced decision-making. Moreover, this im-This will enable enhanced decision-making. Moreover, this im-This will enable enhanced decision-making. Moreover, this im-This will enable enhanced decision-making. Moreover, this im-This will enable enhanced decision-making. Moreover, this im-This will enable enhanced decision-making. Moreover, this im-This will enable enhanced decision-making. Moreover, this im-This will enable enhanced decision-making. Moreover, this im-plies a need to further develop technological competency within plies a need to further develop technological competency within plies a need to further develop technological competency within plies a need to further develop technological competency within plies a need to further develop technological competency within plies a need to further develop technological competency within plies a need to further develop technological competency within plies a need to further develop technological competency within plies a need to further develop technological competency within plies a need to further develop technological competency within plies a need to further develop technological competency within plies a need to further develop technological competency within the Agency to effectively and consistently apply, maintain, and the Agency to effectively and consistently apply, maintain, and the Agency to effectively and consistently apply, maintain, and the Agency to effectively and consistently apply, maintain, and the Agency to effectively and consistently apply, maintain, and the Agency to effectively and consistently apply, maintain, and the Agency to effectively and consistently apply, maintain, and the Agency to effectively and consistently apply, maintain, and the Agency to effectively and consistently apply, maintain, and the Agency to effectively and consistently apply, maintain, and the Agency to effectively and consistently apply, maintain, and update these models and tools. One way to achieve this techno-update these models and tools. One way to achieve this techno-update these models and tools. One way to achieve this techno-update these models and tools. One way to achieve this techno-update these models and tools. One way to achieve this techno-update these models and tools. One way to achieve this techno-update these models and tools. One way to achieve this techno-update these models and tools. One way to achieve this techno-update these models and tools. One way to achieve this techno-update these models and tools. One way to achieve this techno-update these models and tools. One way to achieve this techno-update these models and tools. One way to achieve this techno-logical competency is to increase investment in the development logical competency is to increase investment in the development logical competency is to increase investment in the development logical competency is to increase investment in the development logical competency is to increase investment in the development logical competency is to increase investment in the development logical competency is to increase investment in the development logical competency is to increase investment in the development logical competency is to increase investment in the development logical competency is to increase investment in the development logical competency is to increase investment in the development and training of NASA̓ s scientifi c and engineering workforce in and training of NASA̓ s scientifi c and engineering workforce in and training of NASA̓ s scientifi c and engineering workforce in and training of NASA̓ s scientifi c and engineering workforce in and training of NASA̓ s scientifi c and engineering workforce in and training of NASA̓ s scientifi c and engineering workforce in and training of NASA̓ s scientifi c and engineering workforce in and training of NASA̓ s scientifi c and engineering workforce in and training of NASA̓ s scientifi c and engineering workforce in and training of NASA̓ s scientifi c and engineering workforce in and training of NASA̓ s scientifi c and engineering workforce in and training of NASA̓ s scientifi c and engineering workforce in order to increase their skill base and overall effectiveness.order to increase their skill base and overall effectiveness.order to increase their skill base and overall effectiveness.order to increase their skill base and overall effectiveness.order to increase their skill base and overall effectiveness.order to increase their skill base and overall effectiveness.order to increase their skill base and overall effectiveness.order to increase their skill base and overall effectiveness.order to increase their skill base and overall effectiveness.order to increase their skill base and overall effectiveness.

The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced the Diaz Team assessment:the Diaz Team assessment:the Diaz Team assessment:the Diaz Team assessment:the Diaz Team assessment:

» Technical expertise is being lost within NASA due to Technical expertise is being lost within NASA due to Technical expertise is being lost within NASA due to Technical expertise is being lost within NASA due to Technical expertise is being lost within NASA due to Technical expertise is being lost within NASA due to Technical expertise is being lost within NASA due to Technical expertise is being lost within NASA due to Technical expertise is being lost within NASA due to retirement and the outsourcing of technical profi ciency retirement and the outsourcing of technical profi ciency retirement and the outsourcing of technical profi ciency retirement and the outsourcing of technical profi ciency retirement and the outsourcing of technical profi ciency retirement and the outsourcing of technical profi ciency retirement and the outsourcing of technical profi ciency retirement and the outsourcing of technical profi ciency retirement and the outsourcing of technical profi ciency retirement and the outsourcing of technical profi ciency retirement and the outsourcing of technical profi ciency to contractors. to contractors. to contractors.

» There is a need to have more decision-makers with There is a need to have more decision-makers with There is a need to have more decision-makers with There is a need to have more decision-makers with There is a need to have more decision-makers with There is a need to have more decision-makers with There is a need to have more decision-makers with There is a need to have more decision-makers with There is a need to have more decision-makers with hands-on experience in addition to theoretical knowl-hands-on experience in addition to theoretical knowl-hands-on experience in addition to theoretical knowl-hands-on experience in addition to theoretical knowl-hands-on experience in addition to theoretical knowl-hands-on experience in addition to theoretical knowl-hands-on experience in addition to theoretical knowl-hands-on experience in addition to theoretical knowl-hands-on experience in addition to theoretical knowl-edge. edge.

» Technical expertise needs improvement throughout Technical expertise needs improvement throughout Technical expertise needs improvement throughout Technical expertise needs improvement throughout Technical expertise needs improvement throughout Technical expertise needs improvement throughout Technical expertise needs improvement throughout Technical expertise needs improvement throughout Technical expertise needs improvement throughout Technical expertise needs improvement throughout NASA.NASA.

»» Technical tools and information systems are not there Technical tools and information systems are not there Technical tools and information systems are not there Technical tools and information systems are not there Technical tools and information systems are not there Technical tools and information systems are not there Technical tools and information systems are not there Technical tools and information systems are not there Technical tools and information systems are not there Technical tools and information systems are not there Technical tools and information systems are not there for people to effectively do their jobs. for people to effectively do their jobs. for people to effectively do their jobs. for people to effectively do their jobs. for people to effectively do their jobs. for people to effectively do their jobs. for people to effectively do their jobs.

NASA has taken steps recently to develop systems to identify NASA has taken steps recently to develop systems to identify NASA has taken steps recently to develop systems to identify NASA has taken steps recently to develop systems to identify NASA has taken steps recently to develop systems to identify NASA has taken steps recently to develop systems to identify NASA has taken steps recently to develop systems to identify NASA has taken steps recently to develop systems to identify NASA has taken steps recently to develop systems to identify NASA has taken steps recently to develop systems to identify NASA has taken steps recently to develop systems to identify critical competencies across the Agency. NASA should go fur-critical competencies across the Agency. NASA should go fur-critical competencies across the Agency. NASA should go fur-critical competencies across the Agency. NASA should go fur-critical competencies across the Agency. NASA should go fur-critical competencies across the Agency. NASA should go fur-critical competencies across the Agency. NASA should go fur-critical competencies across the Agency. NASA should go fur-critical competencies across the Agency. NASA should go fur-critical competencies across the Agency. NASA should go fur-critical competencies across the Agency. NASA should go fur-critical competencies across the Agency. NASA should go fur-ther and develop strategies of continuous investment and prac-ther and develop strategies of continuous investment and prac-ther and develop strategies of continuous investment and prac-ther and develop strategies of continuous investment and prac-ther and develop strategies of continuous investment and prac-ther and develop strategies of continuous investment and prac-ther and develop strategies of continuous investment and prac-ther and develop strategies of continuous investment and prac-ther and develop strategies of continuous investment and prac-ther and develop strategies of continuous investment and prac-ther and develop strategies of continuous investment and prac-tice for assuring that required competencies are maintained and tice for assuring that required competencies are maintained and tice for assuring that required competencies are maintained and tice for assuring that required competencies are maintained and tice for assuring that required competencies are maintained and tice for assuring that required competencies are maintained and tice for assuring that required competencies are maintained and tice for assuring that required competencies are maintained and tice for assuring that required competencies are maintained and tice for assuring that required competencies are maintained and tice for assuring that required competencies are maintained and applied to activities in an appropriate way. The future ability to applied to activities in an appropriate way. The future ability to applied to activities in an appropriate way. The future ability to applied to activities in an appropriate way. The future ability to applied to activities in an appropriate way. The future ability to applied to activities in an appropriate way. The future ability to applied to activities in an appropriate way. The future ability to applied to activities in an appropriate way. The future ability to applied to activities in an appropriate way. The future ability to applied to activities in an appropriate way. The future ability to applied to activities in an appropriate way. The future ability to applied to activities in an appropriate way. The future ability to make technically credible design, test, operational, and safety de-make technically credible design, test, operational, and safety de-make technically credible design, test, operational, and safety de-make technically credible design, test, operational, and safety de-make technically credible design, test, operational, and safety de-make technically credible design, test, operational, and safety de-make technically credible design, test, operational, and safety de-make technically credible design, test, operational, and safety de-make technically credible design, test, operational, and safety de-make technically credible design, test, operational, and safety de-make technically credible design, test, operational, and safety de-cisions will rely on NASA systematically improving its technical cisions will rely on NASA systematically improving its technical cisions will rely on NASA systematically improving its technical cisions will rely on NASA systematically improving its technical cisions will rely on NASA systematically improving its technical cisions will rely on NASA systematically improving its technical cisions will rely on NASA systematically improving its technical cisions will rely on NASA systematically improving its technical cisions will rely on NASA systematically improving its technical cisions will rely on NASA systematically improving its technical cisions will rely on NASA systematically improving its technical cisions will rely on NASA systematically improving its technical capabilities and competencies throughout the Agency.capabilities and competencies throughout the Agency.capabilities and competencies throughout the Agency.capabilities and competencies throughout the Agency.capabilities and competencies throughout the Agency.capabilities and competencies throughout the Agency.capabilities and competencies throughout the Agency.capabilities and competencies throughout the Agency.capabilities and competencies throughout the Agency.

In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address In addition to the actions in the Diaz Team Matrix that address each R-O-F, the Diaz Team has one goal addressing the Techni-each R-O-F, the Diaz Team has one goal addressing the Techni-each R-O-F, the Diaz Team has one goal addressing the Techni-each R-O-F, the Diaz Team has one goal addressing the Techni-each R-O-F, the Diaz Team has one goal addressing the Techni-each R-O-F, the Diaz Team has one goal addressing the Techni-each R-O-F, the Diaz Team has one goal addressing the Techni-each R-O-F, the Diaz Team has one goal addressing the Techni-each R-O-F, the Diaz Team has one goal addressing the Techni-each R-O-F, the Diaz Team has one goal addressing the Techni-each R-O-F, the Diaz Team has one goal addressing the Techni-cal Capabilities category, as shown in Table 6.cal Capabilities category, as shown in Table 6.cal Capabilities category, as shown in Table 6.cal Capabilities category, as shown in Table 6.cal Capabilities category, as shown in Table 6.cal Capabilities category, as shown in Table 6.cal Capabilities category, as shown in Table 6.cal Capabilities category, as shown in Table 6.

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

Technical Capabilities – Diaz Team Goal

The Agency should develop guidelines and metrics for assessing and maintaining its core competencies, including those associated with in-house work.

1 51 5

1.7 ORGANIZATIONAL STRUCTURE

CAIB Report Executive Summary, p9:This report discusses the attributes of an organization that could more safely and reliably operate the inherently risky Space Shuttle, but does not provide a detailed organizational prescription. Among those attributes are: a robust and independent program technical authority that has complete control over specifi cations and require-ments, and waivers to them; an independent safety assurance organization with line authority over all levels of safety oversight; and an organizational culture that refl ects the best characteristics of a learning organization.

NASA’s safety and engineering organizations lack authority and independence.

Agency-wide Themes• NASA must ensure systematic checks-and-bal-

ances are in place.• NASA must implement independent safety and

technical organizations.• Roles and responsibilities must be clearly de-

fi ned and widely understood.

The Diaz Team felt strongly that changes suggested by the CAIB The Diaz Team felt strongly that changes suggested by the CAIB The Diaz Team felt strongly that changes suggested by the CAIB The Diaz Team felt strongly that changes suggested by the CAIB The Diaz Team felt strongly that changes suggested by the CAIB The Diaz Team felt strongly that changes suggested by the CAIB The Diaz Team felt strongly that changes suggested by the CAIB The Diaz Team felt strongly that changes suggested by the CAIB The Diaz Team felt strongly that changes suggested by the CAIB The Diaz Team felt strongly that changes suggested by the CAIB The Diaz Team felt strongly that changes suggested by the CAIB The Diaz Team felt strongly that changes suggested by the CAIB The Diaz Team felt strongly that changes suggested by the CAIB for the Space Shuttle Program were worth serious consideration for the Space Shuttle Program were worth serious consideration for the Space Shuttle Program were worth serious consideration for the Space Shuttle Program were worth serious consideration for the Space Shuttle Program were worth serious consideration for the Space Shuttle Program were worth serious consideration for the Space Shuttle Program were worth serious consideration for the Space Shuttle Program were worth serious consideration for the Space Shuttle Program were worth serious consideration for the Space Shuttle Program were worth serious consideration for the Space Shuttle Program were worth serious consideration for the Space Shuttle Program were worth serious consideration throughout NASA. These changes were observed by the CAIB throughout NASA. These changes were observed by the CAIB throughout NASA. These changes were observed by the CAIB throughout NASA. These changes were observed by the CAIB throughout NASA. These changes were observed by the CAIB throughout NASA. These changes were observed by the CAIB throughout NASA. These changes were observed by the CAIB throughout NASA. These changes were observed by the CAIB throughout NASA. These changes were observed by the CAIB throughout NASA. These changes were observed by the CAIB throughout NASA. These changes were observed by the CAIB throughout NASA. These changes were observed by the CAIB to be needed in NASA̓ s organizational approach to allow for a to be needed in NASA̓ s organizational approach to allow for a to be needed in NASA̓ s organizational approach to allow for a to be needed in NASA̓ s organizational approach to allow for a to be needed in NASA̓ s organizational approach to allow for a to be needed in NASA̓ s organizational approach to allow for a to be needed in NASA̓ s organizational approach to allow for a to be needed in NASA̓ s organizational approach to allow for a to be needed in NASA̓ s organizational approach to allow for a to be needed in NASA̓ s organizational approach to allow for a to be needed in NASA̓ s organizational approach to allow for a to be needed in NASA̓ s organizational approach to allow for a healthy “check-and-balance” system to prevail. healthy “check-and-balance” system to prevail. healthy “check-and-balance” system to prevail. healthy “check-and-balance” system to prevail. healthy “check-and-balance” system to prevail. healthy “check-and-balance” system to prevail. healthy “check-and-balance” system to prevail. healthy “check-and-balance” system to prevail. healthy “check-and-balance” system to prevail.

The CAIB Report had the following to say about the need for The CAIB Report had the following to say about the need for The CAIB Report had the following to say about the need for The CAIB Report had the following to say about the need for The CAIB Report had the following to say about the need for The CAIB Report had the following to say about the need for The CAIB Report had the following to say about the need for The CAIB Report had the following to say about the need for The CAIB Report had the following to say about the need for The CAIB Report had the following to say about the need for The CAIB Report had the following to say about the need for The CAIB Report had the following to say about the need for such controls:such controls:such controls:such controls:

When high-risk technology is the product and lives are When high-risk technology is the product and lives are When high-risk technology is the product and lives are When high-risk technology is the product and lives are When high-risk technology is the product and lives are When high-risk technology is the product and lives are When high-risk technology is the product and lives are When high-risk technology is the product and lives are When high-risk technology is the product and lives are When high-risk technology is the product and lives are When high-risk technology is the product and lives are at stake, safety, oversight, and communication fl ows are at stake, safety, oversight, and communication fl ows are at stake, safety, oversight, and communication fl ows are at stake, safety, oversight, and communication fl ows are at stake, safety, oversight, and communication fl ows are at stake, safety, oversight, and communication fl ows are at stake, safety, oversight, and communication fl ows are at stake, safety, oversight, and communication fl ows are at stake, safety, oversight, and communication fl ows are at stake, safety, oversight, and communication fl ows are critical. The Board found that the Shuttle Program’s nor-critical. The Board found that the Shuttle Program’s nor-critical. The Board found that the Shuttle Program’s nor-critical. The Board found that the Shuttle Program’s nor-critical. The Board found that the Shuttle Program’s nor-critical. The Board found that the Shuttle Program’s nor-critical. The Board found that the Shuttle Program’s nor-critical. The Board found that the Shuttle Program’s nor-critical. The Board found that the Shuttle Program’s nor-critical. The Board found that the Shuttle Program’s nor-mal chain of command and matrix system did not perform mal chain of command and matrix system did not perform mal chain of command and matrix system did not perform mal chain of command and matrix system did not perform mal chain of command and matrix system did not perform mal chain of command and matrix system did not perform mal chain of command and matrix system did not perform mal chain of command and matrix system did not perform mal chain of command and matrix system did not perform mal chain of command and matrix system did not perform mal chain of command and matrix system did not perform a check-and-balance function on either foam or O-rings. a check-and-balance function on either foam or O-rings. a check-and-balance function on either foam or O-rings. a check-and-balance function on either foam or O-rings. a check-and-balance function on either foam or O-rings. a check-and-balance function on either foam or O-rings. a check-and-balance function on either foam or O-rings. a check-and-balance function on either foam or O-rings. a check-and-balance function on either foam or O-rings. a check-and-balance function on either foam or O-rings. (CAIB Report, Chapter 8, p. 198)(CAIB Report, Chapter 8, p. 198)(CAIB Report, Chapter 8, p. 198)(CAIB Report, Chapter 8, p. 198)(CAIB Report, Chapter 8, p. 198)(CAIB Report, Chapter 8, p. 198)(CAIB Report, Chapter 8, p. 198)

NASA must implement CAIB-suggested organizational struc-NASA must implement CAIB-suggested organizational struc-NASA must implement CAIB-suggested organizational struc-NASA must implement CAIB-suggested organizational struc-NASA must implement CAIB-suggested organizational struc-NASA must implement CAIB-suggested organizational struc-NASA must implement CAIB-suggested organizational struc-NASA must implement CAIB-suggested organizational struc-NASA must implement CAIB-suggested organizational struc-NASA must implement CAIB-suggested organizational struc-NASA must implement CAIB-suggested organizational struc-NASA must implement CAIB-suggested organizational struc-NASA must implement CAIB-suggested organizational struc-ture changes. The current check-and-balance infrastructure is ture changes. The current check-and-balance infrastructure is ture changes. The current check-and-balance infrastructure is ture changes. The current check-and-balance infrastructure is ture changes. The current check-and-balance infrastructure is ture changes. The current check-and-balance infrastructure is ture changes. The current check-and-balance infrastructure is ture changes. The current check-and-balance infrastructure is ture changes. The current check-and-balance infrastructure is ture changes. The current check-and-balance infrastructure is ture changes. The current check-and-balance infrastructure is ture changes. The current check-and-balance infrastructure is inadequate. The CAIBʼs answer to this issue was to create an inadequate. The CAIBʼs answer to this issue was to create an inadequate. The CAIBʼs answer to this issue was to create an inadequate. The CAIBʼs answer to this issue was to create an inadequate. The CAIBʼs answer to this issue was to create an inadequate. The CAIBʼs answer to this issue was to create an inadequate. The CAIBʼs answer to this issue was to create an inadequate. The CAIBʼs answer to this issue was to create an inadequate. The CAIBʼs answer to this issue was to create an inadequate. The CAIBʼs answer to this issue was to create an inadequate. The CAIBʼs answer to this issue was to create an inadequate. The CAIBʼs answer to this issue was to create an inadequate. The CAIBʼs answer to this issue was to create an Independent Technical Engineering Authority (ITEA) as a new Independent Technical Engineering Authority (ITEA) as a new Independent Technical Engineering Authority (ITEA) as a new Independent Technical Engineering Authority (ITEA) as a new Independent Technical Engineering Authority (ITEA) as a new Independent Technical Engineering Authority (ITEA) as a new Independent Technical Engineering Authority (ITEA) as a new Independent Technical Engineering Authority (ITEA) as a new Independent Technical Engineering Authority (ITEA) as a new Independent Technical Engineering Authority (ITEA) as a new Independent Technical Engineering Authority (ITEA) as a new Independent Technical Engineering Authority (ITEA) as a new key structural component within NASA for the Space Shuttle key structural component within NASA for the Space Shuttle key structural component within NASA for the Space Shuttle key structural component within NASA for the Space Shuttle key structural component within NASA for the Space Shuttle key structural component within NASA for the Space Shuttle key structural component within NASA for the Space Shuttle key structural component within NASA for the Space Shuttle key structural component within NASA for the Space Shuttle key structural component within NASA for the Space Shuttle key structural component within NASA for the Space Shuttle key structural component within NASA for the Space Shuttle Program. The specifi c authority and responsibilities of that ITEA Program. The specifi c authority and responsibilities of that ITEA Program. The specifi c authority and responsibilities of that ITEA Program. The specifi c authority and responsibilities of that ITEA Program. The specifi c authority and responsibilities of that ITEA Program. The specifi c authority and responsibilities of that ITEA Program. The specifi c authority and responsibilities of that ITEA Program. The specifi c authority and responsibilities of that ITEA Program. The specifi c authority and responsibilities of that ITEA Program. The specifi c authority and responsibilities of that ITEA Program. The specifi c authority and responsibilities of that ITEA Program. The specifi c authority and responsibilities of that ITEA Program. The specifi c authority and responsibilities of that ITEA must be developed in accordance with the CAIB. However, the must be developed in accordance with the CAIB. However, the must be developed in accordance with the CAIB. However, the must be developed in accordance with the CAIB. However, the must be developed in accordance with the CAIB. However, the must be developed in accordance with the CAIB. However, the must be developed in accordance with the CAIB. However, the must be developed in accordance with the CAIB. However, the must be developed in accordance with the CAIB. However, the must be developed in accordance with the CAIB. However, the must be developed in accordance with the CAIB. However, the must be developed in accordance with the CAIB. However, the Diaz Team concluded that all programs would benefi t from an Diaz Team concluded that all programs would benefi t from an Diaz Team concluded that all programs would benefi t from an Diaz Team concluded that all programs would benefi t from an Diaz Team concluded that all programs would benefi t from an Diaz Team concluded that all programs would benefi t from an Diaz Team concluded that all programs would benefi t from an Diaz Team concluded that all programs would benefi t from an Diaz Team concluded that all programs would benefi t from an Diaz Team concluded that all programs would benefi t from an Diaz Team concluded that all programs would benefi t from an Diaz Team concluded that all programs would benefi t from an Diaz Team concluded that all programs would benefi t from an independent engineering authority concept that is applied across independent engineering authority concept that is applied across independent engineering authority concept that is applied across independent engineering authority concept that is applied across independent engineering authority concept that is applied across independent engineering authority concept that is applied across independent engineering authority concept that is applied across independent engineering authority concept that is applied across independent engineering authority concept that is applied across independent engineering authority concept that is applied across independent engineering authority concept that is applied across independent engineering authority concept that is applied across the Agency, to ensure that technical standards are being met. the Agency, to ensure that technical standards are being met. the Agency, to ensure that technical standards are being met. the Agency, to ensure that technical standards are being met. the Agency, to ensure that technical standards are being met. the Agency, to ensure that technical standards are being met. the Agency, to ensure that technical standards are being met. the Agency, to ensure that technical standards are being met. the Agency, to ensure that technical standards are being met. the Agency, to ensure that technical standards are being met. the Agency, to ensure that technical standards are being met. the Agency, to ensure that technical standards are being met. the Agency, to ensure that technical standards are being met. Therefore, the Team recommends that an independent technical Therefore, the Team recommends that an independent technical Therefore, the Team recommends that an independent technical Therefore, the Team recommends that an independent technical Therefore, the Team recommends that an independent technical Therefore, the Team recommends that an independent technical Therefore, the Team recommends that an independent technical Therefore, the Team recommends that an independent technical Therefore, the Team recommends that an independent technical Therefore, the Team recommends that an independent technical Therefore, the Team recommends that an independent technical Therefore, the Team recommends that an independent technical authority concept be applied on all technical programs. As rec-authority concept be applied on all technical programs. As rec-authority concept be applied on all technical programs. As rec-authority concept be applied on all technical programs. As rec-authority concept be applied on all technical programs. As rec-authority concept be applied on all technical programs. As rec-authority concept be applied on all technical programs. As rec-authority concept be applied on all technical programs. As rec-authority concept be applied on all technical programs. As rec-authority concept be applied on all technical programs. As rec-authority concept be applied on all technical programs. As rec-authority concept be applied on all technical programs. As rec-ommended in the CAIB R7.5-1, the ITEA must, at a minimum: ommended in the CAIB R7.5-1, the ITEA must, at a minimum: ommended in the CAIB R7.5-1, the ITEA must, at a minimum: ommended in the CAIB R7.5-1, the ITEA must, at a minimum: ommended in the CAIB R7.5-1, the ITEA must, at a minimum: ommended in the CAIB R7.5-1, the ITEA must, at a minimum: ommended in the CAIB R7.5-1, the ITEA must, at a minimum: ommended in the CAIB R7.5-1, the ITEA must, at a minimum: ommended in the CAIB R7.5-1, the ITEA must, at a minimum: ommended in the CAIB R7.5-1, the ITEA must, at a minimum: ommended in the CAIB R7.5-1, the ITEA must, at a minimum: ommended in the CAIB R7.5-1, the ITEA must, at a minimum: develop and maintain, and be the sole waiver-granting authority develop and maintain, and be the sole waiver-granting authority develop and maintain, and be the sole waiver-granting authority develop and maintain, and be the sole waiver-granting authority develop and maintain, and be the sole waiver-granting authority develop and maintain, and be the sole waiver-granting authority develop and maintain, and be the sole waiver-granting authority develop and maintain, and be the sole waiver-granting authority develop and maintain, and be the sole waiver-granting authority develop and maintain, and be the sole waiver-granting authority develop and maintain, and be the sole waiver-granting authority develop and maintain, and be the sole waiver-granting authority for all technical standards; conduct trend and risk analyses and for all technical standards; conduct trend and risk analyses and for all technical standards; conduct trend and risk analyses and for all technical standards; conduct trend and risk analyses and for all technical standards; conduct trend and risk analyses and for all technical standards; conduct trend and risk analyses and for all technical standards; conduct trend and risk analyses and for all technical standards; conduct trend and risk analyses and for all technical standards; conduct trend and risk analyses and for all technical standards; conduct trend and risk analyses and for all technical standards; conduct trend and risk analyses and for all technical standards; conduct trend and risk analyses and for all technical standards; conduct trend and risk analyses and own the failure mode, effects analyses, and hazard reporting sys-own the failure mode, effects analyses, and hazard reporting sys-own the failure mode, effects analyses, and hazard reporting sys-own the failure mode, effects analyses, and hazard reporting sys-own the failure mode, effects analyses, and hazard reporting sys-own the failure mode, effects analyses, and hazard reporting sys-own the failure mode, effects analyses, and hazard reporting sys-own the failure mode, effects analyses, and hazard reporting sys-own the failure mode, effects analyses, and hazard reporting sys-own the failure mode, effects analyses, and hazard reporting sys-own the failure mode, effects analyses, and hazard reporting sys-own the failure mode, effects analyses, and hazard reporting sys-

tems; and decide what is and what is not an anomalous event. tems; and decide what is and what is not an anomalous event. tems; and decide what is and what is not an anomalous event. tems; and decide what is and what is not an anomalous event. tems; and decide what is and what is not an anomalous event. tems; and decide what is and what is not an anomalous event. tems; and decide what is and what is not an anomalous event. tems; and decide what is and what is not an anomalous event. tems; and decide what is and what is not an anomalous event. tems; and decide what is and what is not an anomalous event. tems; and decide what is and what is not an anomalous event. The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced The feedback from Safety and Mission Success Week reinforced the Diaz Team assessment:the Diaz Team assessment:the Diaz Team assessment:the Diaz Team assessment:the Diaz Team assessment:the Diaz Team assessment:

» Have our leadership thoroughly evaluate the system of Have our leadership thoroughly evaluate the system of Have our leadership thoroughly evaluate the system of Have our leadership thoroughly evaluate the system of Have our leadership thoroughly evaluate the system of Have our leadership thoroughly evaluate the system of Have our leadership thoroughly evaluate the system of Have our leadership thoroughly evaluate the system of Have our leadership thoroughly evaluate the system of Have our leadership thoroughly evaluate the system of safety and mission success with regard to the plethora safety and mission success with regard to the plethora safety and mission success with regard to the plethora safety and mission success with regard to the plethora safety and mission success with regard to the plethora safety and mission success with regard to the plethora safety and mission success with regard to the plethora safety and mission success with regard to the plethora safety and mission success with regard to the plethora safety and mission success with regard to the plethora safety and mission success with regard to the plethora of organizations having responsibility for oversee-of organizations having responsibility for oversee-of organizations having responsibility for oversee-of organizations having responsibility for oversee-of organizations having responsibility for oversee-of organizations having responsibility for oversee-of organizations having responsibility for oversee-of organizations having responsibility for oversee-of organizations having responsibility for oversee-ing the safety and quality of work performed with the ing the safety and quality of work performed with the ing the safety and quality of work performed with the ing the safety and quality of work performed with the ing the safety and quality of work performed with the ing the safety and quality of work performed with the ing the safety and quality of work performed with the ing the safety and quality of work performed with the ing the safety and quality of work performed with the ing the safety and quality of work performed with the express intent of making it simpler, safer and higher express intent of making it simpler, safer and higher express intent of making it simpler, safer and higher express intent of making it simpler, safer and higher express intent of making it simpler, safer and higher express intent of making it simpler, safer and higher express intent of making it simpler, safer and higher express intent of making it simpler, safer and higher express intent of making it simpler, safer and higher express intent of making it simpler, safer and higher quality/reliability while reducing the overlapping quality/reliability while reducing the overlapping quality/reliability while reducing the overlapping quality/reliability while reducing the overlapping quality/reliability while reducing the overlapping quality/reliability while reducing the overlapping quality/reliability while reducing the overlapping quality/reliability while reducing the overlapping quality/reliability while reducing the overlapping responsibilities.responsibilities.responsibilities.responsibilities.

» Organizations must be structured to provide a more Organizations must be structured to provide a more Organizations must be structured to provide a more Organizations must be structured to provide a more Organizations must be structured to provide a more Organizations must be structured to provide a more Organizations must be structured to provide a more Organizations must be structured to provide a more Organizations must be structured to provide a more effective balance between program schedule/cost man-effective balance between program schedule/cost man-effective balance between program schedule/cost man-effective balance between program schedule/cost man-effective balance between program schedule/cost man-effective balance between program schedule/cost man-effective balance between program schedule/cost man-effective balance between program schedule/cost man-effective balance between program schedule/cost man-effective balance between program schedule/cost man-effective balance between program schedule/cost man-agement and technical review authority.agement and technical review authority.agement and technical review authority.agement and technical review authority.agement and technical review authority.agement and technical review authority.agement and technical review authority.

» NASA should look to eliminate or modify organi-NASA should look to eliminate or modify organi-NASA should look to eliminate or modify organi-NASA should look to eliminate or modify organi-NASA should look to eliminate or modify organi-NASA should look to eliminate or modify organi-NASA should look to eliminate or modify organi-NASA should look to eliminate or modify organi-NASA should look to eliminate or modify organi-zational distinctions that create divisions within the zational distinctions that create divisions within the zational distinctions that create divisions within the zational distinctions that create divisions within the zational distinctions that create divisions within the zational distinctions that create divisions within the zational distinctions that create divisions within the zational distinctions that create divisions within the zational distinctions that create divisions within the Agency, which potentially foster competition rather Agency, which potentially foster competition rather Agency, which potentially foster competition rather Agency, which potentially foster competition rather Agency, which potentially foster competition rather Agency, which potentially foster competition rather Agency, which potentially foster competition rather Agency, which potentially foster competition rather Agency, which potentially foster competition rather than collaboration.than collaboration.than collaboration.than collaboration.than collaboration.

» Clearly defi ne roles, responsibilities, and accountabil-Clearly defi ne roles, responsibilities, and accountabil-Clearly defi ne roles, responsibilities, and accountabil-Clearly defi ne roles, responsibilities, and accountabil-Clearly defi ne roles, responsibilities, and accountabil-Clearly defi ne roles, responsibilities, and accountabil-Clearly defi ne roles, responsibilities, and accountabil-Clearly defi ne roles, responsibilities, and accountabil-Clearly defi ne roles, responsibilities, and accountabil-Clearly defi ne roles, responsibilities, and accountabil-ity starting with the role of the Agency/Center, then ity starting with the role of the Agency/Center, then ity starting with the role of the Agency/Center, then ity starting with the role of the Agency/Center, then ity starting with the role of the Agency/Center, then ity starting with the role of the Agency/Center, then ity starting with the role of the Agency/Center, then ity starting with the role of the Agency/Center, then ity starting with the role of the Agency/Center, then ity starting with the role of the Agency/Center, then on down, to describe strategically what we want to do, on down, to describe strategically what we want to do, on down, to describe strategically what we want to do, on down, to describe strategically what we want to do, on down, to describe strategically what we want to do, on down, to describe strategically what we want to do, on down, to describe strategically what we want to do, on down, to describe strategically what we want to do, on down, to describe strategically what we want to do, on down, to describe strategically what we want to do, who will do it, and who is responsible for what. who will do it, and who is responsible for what. who will do it, and who is responsible for what. who will do it, and who is responsible for what. who will do it, and who is responsible for what. who will do it, and who is responsible for what. who will do it, and who is responsible for what. who will do it, and who is responsible for what. who will do it, and who is responsible for what. who will do it, and who is responsible for what.

NASA should seriously consider CAIB-suggested organiza-NASA should seriously consider CAIB-suggested organiza-NASA should seriously consider CAIB-suggested organiza-NASA should seriously consider CAIB-suggested organiza-NASA should seriously consider CAIB-suggested organiza-NASA should seriously consider CAIB-suggested organiza-NASA should seriously consider CAIB-suggested organiza-NASA should seriously consider CAIB-suggested organiza-NASA should seriously consider CAIB-suggested organiza-NASA should seriously consider CAIB-suggested organiza-NASA should seriously consider CAIB-suggested organiza-NASA should seriously consider CAIB-suggested organiza-tional structure changes across the Agency. The organizational tional structure changes across the Agency. The organizational tional structure changes across the Agency. The organizational tional structure changes across the Agency. The organizational tional structure changes across the Agency. The organizational tional structure changes across the Agency. The organizational tional structure changes across the Agency. The organizational tional structure changes across the Agency. The organizational tional structure changes across the Agency. The organizational tional structure changes across the Agency. The organizational tional structure changes across the Agency. The organizational tional structure changes across the Agency. The organizational tional structure changes across the Agency. The organizational structure can help clarify roles and responsibilities of individual structure can help clarify roles and responsibilities of individual structure can help clarify roles and responsibilities of individual structure can help clarify roles and responsibilities of individual structure can help clarify roles and responsibilities of individual structure can help clarify roles and responsibilities of individual structure can help clarify roles and responsibilities of individual structure can help clarify roles and responsibilities of individual structure can help clarify roles and responsibilities of individual structure can help clarify roles and responsibilities of individual structure can help clarify roles and responsibilities of individual structure can help clarify roles and responsibilities of individual employees, work groups, and leadership. In transitioning to the employees, work groups, and leadership. In transitioning to the employees, work groups, and leadership. In transitioning to the employees, work groups, and leadership. In transitioning to the employees, work groups, and leadership. In transitioning to the employees, work groups, and leadership. In transitioning to the employees, work groups, and leadership. In transitioning to the employees, work groups, and leadership. In transitioning to the employees, work groups, and leadership. In transitioning to the employees, work groups, and leadership. In transitioning to the employees, work groups, and leadership. In transitioning to the employees, work groups, and leadership. In transitioning to the employees, work groups, and leadership. In transitioning to the new organization, every member of the workforce should be able new organization, every member of the workforce should be able new organization, every member of the workforce should be able new organization, every member of the workforce should be able new organization, every member of the workforce should be able new organization, every member of the workforce should be able new organization, every member of the workforce should be able new organization, every member of the workforce should be able new organization, every member of the workforce should be able new organization, every member of the workforce should be able new organization, every member of the workforce should be able new organization, every member of the workforce should be able to answer three basic questions:to answer three basic questions:to answer three basic questions:to answer three basic questions:to answer three basic questions:to answer three basic questions:to answer three basic questions:to answer three basic questions:

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

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

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

A healthy organizational structure is a solid foundation to help A healthy organizational structure is a solid foundation to help A healthy organizational structure is a solid foundation to help A healthy organizational structure is a solid foundation to help A healthy organizational structure is a solid foundation to help A healthy organizational structure is a solid foundation to help A healthy organizational structure is a solid foundation to help A healthy organizational structure is a solid foundation to help A healthy organizational structure is a solid foundation to help A healthy organizational structure is a solid foundation to help A healthy organizational structure is a solid foundation to help A healthy organizational structure is a solid foundation to help A healthy organizational structure is a solid foundation to help enable our people to succeed. NASA now has the opportunity enable our people to succeed. NASA now has the opportunity enable our people to succeed. NASA now has the opportunity enable our people to succeed. NASA now has the opportunity enable our people to succeed. NASA now has the opportunity enable our people to succeed. NASA now has the opportunity enable our people to succeed. NASA now has the opportunity enable our people to succeed. NASA now has the opportunity enable our people to succeed. NASA now has the opportunity enable our people to succeed. NASA now has the opportunity enable our people to succeed. NASA now has the opportunity enable our people to succeed. NASA now has the opportunity to examine its organizational structure and redesign or create to examine its organizational structure and redesign or create to examine its organizational structure and redesign or create to examine its organizational structure and redesign or create to examine its organizational structure and redesign or create to examine its organizational structure and redesign or create to examine its organizational structure and redesign or create to examine its organizational structure and redesign or create to examine its organizational structure and redesign or create to examine its organizational structure and redesign or create to examine its organizational structure and redesign or create to examine its organizational structure and redesign or create new organizational elements that are inherently healthier and new organizational elements that are inherently healthier and new organizational elements that are inherently healthier and new organizational elements that are inherently healthier and new organizational elements that are inherently healthier and new organizational elements that are inherently healthier and new organizational elements that are inherently healthier and new organizational elements that are inherently healthier and new organizational elements that are inherently healthier and new organizational elements that are inherently healthier and new organizational elements that are inherently healthier and new organizational elements that are inherently healthier and succeed in creating the proper checks-and-balances and chains succeed in creating the proper checks-and-balances and chains succeed in creating the proper checks-and-balances and chains succeed in creating the proper checks-and-balances and chains succeed in creating the proper checks-and-balances and chains succeed in creating the proper checks-and-balances and chains succeed in creating the proper checks-and-balances and chains succeed in creating the proper checks-and-balances and chains succeed in creating the proper checks-and-balances and chains succeed in creating the proper checks-and-balances and chains succeed in creating the proper checks-and-balances and chains succeed in creating the proper checks-and-balances and chains of accountability to enable effective communication and deci-of accountability to enable effective communication and deci-of accountability to enable effective communication and deci-of accountability to enable effective communication and deci-of accountability to enable effective communication and deci-of accountability to enable effective communication and deci-of accountability to enable effective communication and deci-of accountability to enable effective communication and deci-of accountability to enable effective communication and deci-of accountability to enable effective communication and deci-of accountability to enable effective communication and deci-of accountability to enable effective communication and deci-of accountability to enable effective communication and deci-sion-making.sion-making.sion-making.sion-making.

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

Organizational Structure – Diaz Team Goal

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