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Safety Recommendation Details

Safety Recommendation A-15-025
Details
Synopsis: On October 31, 2014, at 1007:32 Pacific daylight time, the SpaceShipTwo (SS2) reusable suborbital rocket, N339SS, operated by Scaled Composites LLC (Scaled), broke up into multiple pieces during a rocket-powered test flight and impacted terrain over a 5-mile area near Koehn Dry Lake, California. The pilot received serious injuries, and the copilot received fatal injuries. SS2 was destroyed, and no one on the ground was injured as a result of the falling debris. SS2 had been released from its launch vehicle, WhiteKnightTwo (WK2), N348MS, about 13 seconds before the structural breakup. Scaled was operating SS2 under an experimental permit issued by the Federal Aviation Administration’s (FAA) Office of Commercial Space Transportation (AST) according to the provisions of 14 Code of Federal Regulations (CFR) Part 437.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Direct Office of Commercial Space Transportation (AST) management to work with AST technical staff to (1) develop clearer policies, practices, and procedures that allow direct communications between staff and applicants, (2) provide clearer guidance on evaluating commercial space transportation permits, waivers, and licenses, and (3) better define the line between the information needed to ensure public safety and the information pertaining more broadly to ensuring mission success.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: Koehn Dry Lake, CA, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA15MA019
Accident Reports: In-Flight Breakup During Test Flight Scaled Composites SpaceShipTwo, N339SS Near Koehn Dry Lake, California October 31, 2014
Report #: AAR-15-02
Accident Date: 10/31/2014
Issue Date: 8/4/2015
Date Closed: 2/10/2017
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 2/10/2017
Response: In your previous letter, you indicated that to address this recommendation, you had developed two policy documents, P-002, “License and Permit Application Reviews and Issuance Procedures,” and P-011, “Pre-Application Consultation Process.” Although these procedures addressed the issues in this recommendation, we were concerned that they may institutionalize the procedures and practices that we found in our investigation of the SpaceShipTwo accident, and we asked that you describe how P-002 and P-011 address those issues, including the “filtering” and “scrubbing” of questions, the lack of direct communication between AST technical staff and the applicant’s technical staff, and the pressure on AST technical staff to complete their evaluation within 120 days, even when technical questions remained unanswered despite being needed to complete an appropriate evaluation. In your current letter, you describe the meetings and procedures, as well as the composition of the various teams involved in pre application coordination and license or permit evaluations. These procedures include discussing issues such as question filtering and scrubbing and communication between AST technical staff and the applicant’s technical staff, as well as safeguards to prevent pressure from management to complete an evaluation within 120 days, even when technical questions remain unanswered. In your previous letter, you also indicated that AST was comprehensively upgrading its safety management system (SMS). In our report about the SpaceShipTwo accident, we said that we were encouraged by AST’s progress in implementing SMS and we believed that this recommendation would be satisfied if SMS principles were followed. However, in our January 11, 2016, letter, we said that we were concerned by the statement in your October 30, 2015, letter that you were developing your SMS for AST because “it is critical that all AST staff members understand the FAA’s statutory authority is limited to the protection of public safety and property, national security and foreign policy interests of the United States.” In our report about the SpaceShipTwo accident, we discussed that the dividing line between the questions that need to be asked to determine public risk and those to assess mission objectives was not always apparent; certain aspects of a vehicle’s design and operation could impact both public safety and mission safety assurance. We were concerned that the purpose of AST’s SMS would be to limit its review to a narrowly defined interpretation of your statutory authority, and that such a narrow interpretation would not be consistent with our recommendation. Your current letter included a copy of the December 2015 version of the AST’s SMS manual. We reviewed Appendix A, “Public Safety During Commercial Space Operations,” of this manual, and it addresses our concerns; therefore, Safety Recommendation A-15-25 is classified CLOSED—ACCEPTABLE ACTION.

From: FAA
To: NTSB
Date: 12/6/2016
Response: -From Michael P. Huerta, Administrator: AST completed a comprehensive revision of our Safety Management System (SMS) manual to more clearly articulate our safety policy, safety risk management, safety assurance, and safety promotion for commercial space transportation. The AST SMS reflects an integrated framework of formalized roles, responsibilities, accountabilities, policies, and procedures that are used to manage safety in the course of AST's day to day operations. The revised AST SMS Manual was published in December 2015, and all AST staff were subsequently trained on the content. Further, all new staff are trained in the SMS as part of the new employee orientation. The AST SMS Manual is available at the following Web site: https://www.faa.gov/about/initiatives/sms/referencelibrary/policyand_requirements/media/AST_SMS_Manual_V2.0.pdf The Board requested that we provide additional clarity in two areas of concern: the first is a perceived Jack of technical staff engagement with the applicant, and the other is how staff are guided in considerations that may affect both public safety and mission assurance aspects within our revised SMS framework. Both of these areas are addressed in our P-002, License and Permit Application Reviews and Issuance Procedures, and P-0 I I, Pre-Application Consultation Process, documents and in our SMS. Under our framework, cross-functional teams comprised of staff from all operational divisions conduct both the pre-application coordination and license or permit evaluations. Integrated team operational practices are intended to provide effective communications both between staff and applicants and within AST. Pre-application and evaluation staff team leads are responsible for scheduling meetings with applicants, and the team leads are required to invite all team members to these technical meetings. Team members may opt not to participate in a particular meeting if the subject of the meeting is outside their specific area of interest or responsibility. Technical staff that are supporting teams are responsible for raising any potential issue or concern that they may have during the course of their activities, with the goal that these issues or concerns are identified as early as possible and resolved within the team. If, however, staff cannot resolve concerns within the team there are several avenues for them to elevate their concerns with management. AST management uses several meeting venues to encourage open communication and ensure issues are identified, views are heard and discussed, and appropriate actions are taken to disposition and resolve them. The associated meeting structure includes: 1) Project Dashboard and Issues (POI) Meetings: POI weekly meetings are designed to enhance internal coordination, communications, and transparency by tracking all projects throughout the regulatory safety lifecycle. The meetings provide an opportunity to identify and address any issues encountered, including technical, policy, resource, schedule, or priority issues. Team leads have a responsibility to raise any unresolved issues or concerns that exist within the ir teams at the dashboard and issues meeting. If necessary during the meeting, management may put forth a path to resolve the issue, which may cover a range of approaches. such as providing input and consideration for continued team deliberations or requiring the team to develop options in preparation for a Technical Review Board (TRB) determination. 2) TRB Meetings: TRBs are used to assess, discuss, and make formal decisions regarding the development, application, and adequacy of applicable policies and regulations related to ongoing or future evaluations. TRBs are most frequently convened when the proposed vehicles or their operations contain novel or unique aspects that were not previously encountered within the regulatory framework. 3) Management Review Board (MRB) Meetings: MRBs are used to make formal decisions regarding the issuance of authorizations. As with the other meetings, MRBs include participation from a ll AST divisions and are open to all AST staff as a mechanism to raise concerns for any reason. During MRB meetings, teams provide management their recommendations related to the potential authorization decision, and they are also required to identify any dissenting views that are held within the team for consideration.

From: NTSB
To: FAA
Date: 1/11/2016
Response: We are concerned by your statement that AST technical staff members have always been engaged in direct communications with applicants on technical matters. We found the opposite in our investigation of the SpaceShipTwo accident. We issued this recommendation because we found that, at the time of the evaluation of Scaled’s experimental permit applications, AST management underutilized AST evaluators’ expertise, even though the AST staff understood the risks associated with commercial space flight. AST management appeared to be more concerned with ensuring that the FAA’s authority was not being exceeded beyond defined limits and maintaining the timeframe in which to approve experimental permit applications. Further, we found that the filtering of questions and the lack of direct communication between AST technical staff and Scaled technical staff impeded Scaled’s ability to take advantage of AST’s safety expertise. We note that you recently developed and issued new internal operating procedures P 011 covering pre-application coordination with prospective applicants, and that you revised P 002 for conducting reviews and issuing licenses and experimental permits. You indicated that each of these procedures provides comprehensive guidance for the composition, management, and responsibilities of AST teams working in these areas, including such areas as coordination and communications within the team and with an applicant. The procedures also define the statutory basis and procedures used for conducting licensing and permit evaluations. The procedures also discuss the resolution of technical issues within the team, and the elevation of these issues to AST management if they cannot be resolved at the team level. Although these procedures address issues in this recommendation, we are concerned that the procedures may institutionalize the procedures and practices that we found in the SpaceShipTwo investigation. We ask that you describe how P-011 and P-002 address the “filtering” and “scrubbing” of questions and the lack of direct communication between AST technical staff and the applicant’s technical staff, as well as the pressure on AST technical staff to complete their evaluation within 120 days even when there are unanswered technical questions that need to be answered before an appropriate evaluation can be completed. In your letter, you indicated that AST is conducting a comprehensive upgrade of its safety management system (SMS). In our report about the SpaceShipTwo accident, we said that we were encouraged by AST’s progress in implementing SMS and we believed that, if SMS principles were followed, they would constitute an effective means for enhancing the regulatory oversight of the commercial space industry and would satisfy this recommendation. However, we are concerned by your statement that you are developing your SMS for AST because “it is critical that all AST staff members understand the FAA’s statutory authority is limited to the protection of public safety and property, national security and foreign policy interests of the United States.” In our report, we discussed that the dividing line between the questions that need to be asked to determine the risk to the public and those to assess mission objectives is not always apparent because certain aspects of a vehicle’s design and operation could impact both public safety and mission safety assurance. Therefore, AST technical staff needs to fully understand the factors that might be critical to public safety, such as system failure modes and their effects, the potential for human errors that could contribute to a divergence from operating area containment boundaries, and hazard causes and controls. We are concerned that the purpose of AST’s SMS will be to limit AST’s review to a narrowly defined interpretation of your statutory authority, and that such a narrow interpretation will not be consistent with our recommendation to better define the line between the information needed to ensure public safety and the information pertaining more broadly to ensuring mission success. As we discussed in our report, the development and use of an effective SMS will satisfy this recommendation. We ask that you respond to our concerns regarding P-011 and P-002, and the new SMS. Pending your responses to those concerns, and completion of the SMS for AST, Safety Recommendation A-15-25 is classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 10/30/2015
Response: -From Michael P. Huerta, Administrator: AST technical staff members have always been, and will continue to be, engaged in direct communications with applicants on technical matters. However, the FAA has recognized the need to improve the guidance and policy provided for our technical staff. As a result, the FAA has taken steps to clarify and improve communications among the staff, management, and applicants during the permit and licensing evaluation process. Upgrades to AST's procedures were completed in accordance with AST's September 2014 business plan. Under this plan, AST developed and issued in March 201 5 a new internal operating procedures document, P-0 11 , covering pre-application coordination with prospective applicants. AST also revised and consolidated its internal procedures for conducting reviews and issuing licenses and experimental permits with the release of P-002 in August 2015. Each of these procedures provides comprehensive guidance for: • The composition, management, and responsibilities of AST teams working in these areas, including such areas as coordination and communications within the team and with the applicant; • Defining the statutory basis and conducting licensing and permit evaluations in accordance with the CST regulations and their associated FAA guidance and policy; and • Resolution of technical issues within the team, and the elevation of these issues to AST management if they cannot be resolved at the team level. Elevation to management is also required in cases where waivers, equivalent levels of safety, or the existing regulations, guidance or policy may not be sufficient due to novel aspects of proposed vehicle or its operations. AST uses a Management Review Board (MRB) process when making license or permit determinations, including the need for any waivers or equivalent levels of safety findings. The MRB is made up of AST's executive leadership, its division managers, and chief engineer. MRB meetings are open to all AST staff members and all AST staff and management are actively encouraged to raise any concerns associated with the license or permit review during MRB meetings. It is critical that all AST staff members understand the FAA's statutory authority is limited to the protection of public safety and property, national security and foreign policy interests of the United States. To support this need, AST is also conducting a comprehensive upgrade of its Safety Management System (SMS) process to more clearly articulate our safety policy, safety risk management, safety assurance, and safety promotion within the context of our legislative authority and regulatory framework for CST. The upgrade will also clarify the roles and responsibilities of AST's management and staff in accordance with the recent improvements to AST operating practices and lessons learned. All AST personnel will receive training on the upgraded SMS. The revised SMS document and the training package are both targeted to be available by the beginning of Calendar Year 2016.