The full report is online as a Adobe Acrobat file (473K)

Executive Summary

This second report, prepared by the Mars Climate Orbiter Mishap Investigation Board,
presents a vision and recommendations to maximize the probability of success for future
space missions. The Mars Climate Orbiter Phase I Report, released Nov. 10, 1999,
identified the root cause and factors contributing to the Mars Climate Orbiter failure. The
charter for this second report is to derive lessons learned from that failure and from other
failed missions – as well as some successful ones – and from them create a formula for
future mission success.

The Mars Climate Orbiter mission was conducted under NASA’s “Faster, Better,
Cheaper” philosophy, developed in recent years to enhance innovation, productivity and
cost-effectiveness of America’s space program. The “Faster, Better, Cheaper” paradigm
has successfully challenged project teams to infuse new technologies and processes that
allow NASA to do more with less. The success of “Faster, Better, Cheaper” is tempered
by the fact that some projects and programs have put too much emphasis on cost and
schedule reduction (the “Faster” and “Cheaper” elements of the paradigm). At the same
time, they have failed to instill sufficient rigor in risk management throughout the
mission lifecycle. These actions have increased risk to an unacceptable level on these

The Mishap Investigation Board conducted a series of meetings over several months with
the Jet Propulsion Laboratory and Lockheed Martin Astronautics to better understand the
issues that led to the failure of the Mars Climate Orbiter. The Board found that the Mars
Surveyor Program, agreed to significant cuts in monetary and personnel resources
available to support the Mars Climate Orbiter mission, as compared to previous projects.
More importantly, the project failed to introduce sufficient discipline in the processes
used to develop, validate and operate the spacecraft; nor did it adequately instill a mission
success culture that would shore up the risk introduced by these cuts. These process and
project leadership deficiencies introduced sufficient risk to compromise mission success
to the point of mission failure.

It should be noted that despite these deficiencies, the spacecraft operated as commanded
and the mission was categorized as extremely successful until right before Mars orbit
insertion. This is a testament to the hard work and dedication of the entire Mars Climate
Orbiter team. The Board recognizes that mistakes and deficiencies occur on all
spacecraft projects. It is imperative that all spacecraft projects have sufficient processes
in place to catch mistakes before they become detrimental to mission success.
Unfortunately for the Mars Climate Orbiter, the processes in place did not catch the root
cause and contributing navigational factors that ultimately led to mission failure.
Building upon the lessons learned from the Mars Climate Orbiter and a review of seven
other failure investigation board results, this second report puts forth a new vision for
NASA programs and projects – one that will improve mission success within the

context of the “Faster, Better, Cheaper” paradigm. This vision, Mission Success First,
entails a new NASA culture and new methods of managing projects. To proceed with
this culture shift, mission success must become the highest priority at all levels of the
program/project and the institutional organization. All individuals should feel ownership
and accountability, not only for their own work, but for the success of the entire mission.
Examining the current state of NASA’s program and project management environment,
the Board found that a significant infrastructure of processes and requirements already is
in place to enable robust program and project management. However, these processes
are not being adequately implemented within the context of “Faster, Better, Cheaper.”
To move toward the ideal vision of Mission Success First, the Board makes a series of
observations and recommendations that are grouped into four categories, providing a
guide by which to measure progress.

1) People

The Board recognizes that one of the most important assets to a program and project is its
people. Success means starting with top-notch people and creating the right cultural
environment in which they can excel. Thus, Mission Success First demands that every
individual on the program/project team continuously employ solid engineering and
scientific discipline, take personal ownership for their product development efforts and
continuously manage risk in order to design, develop and deliver robust systems capable
of supporting all mission scenarios.

Teamwork is critical for mission success. Good communication between all project
elements – government and contractor, engineer and scientist – is essential to
maintaining an effective team. To ensure good teamwork, the project manager must
guarantee an appropriate level of staffing, and all roles and responsibilities must be
clearly defined.

2) Process

Even the best people with the best motivation and teamwork need a set of guidelines to
ensure mission success. In most cases NASA has very good processes in place, but there
are a few areas for improvement.

A concise set of mission success criteria should be developed and frozen early in the
project life cycle.

During the mission formulation process, the program office and the project should
perform the system trades necessary to scope out the expected costs for mission success.
This should be accomplished independently of any predefined dollar cap. If necessary,
consider mission scope changes to drive the costs to a level that the program can afford.
Scope should never be decreased below a minimum threshold for science and for
technical achievement as defined by the mission success criteria.

Both the project and the program should hold adequate contingency reserves, to ensure
that mission success is achievable. Projects and programs that wind up with inadequate
funding should obtain more funds or consider cancellation before proceeding with
inadequate funds.

Close attention should be paid from project outset to the plan for transition between
development and operations. Adequate systems engineering staffing, particularly a
mission systems engineer, should be in place to provide a bridge during the transition
between development and operations, and also to support risk management trade studies.
Greater attention needs to be paid to risk identification and management. Risk
management should be employed throughout the life cycle of the project, much the way
cost, schedule and content are managed. Risk, therefore, becomes the “fourth dimension”
of project management – treated equally as important as cost and schedule.

Project managers should copy the checklist located in the back of this report, putting it to
constant use and adding to it in order to benchmark the performance of their project team.
Moreover, this checklist should be distributed to all members of the project team as a
360-degree benchmark tool, to identify and reduce potential risk areas.

3) Execution

Most mission failures and serious errors can be traced to a breakdown in existing
communication channels, or failure to follow existing processes – in other words, a
failure in execution. To successfully shift to the Mission Success First culture, it is
necessary for the institutional line management to become more engaged in the execution
of a project. As such, line managers at the field centers need to be held accountable for
the success of all missions at their centers.

Let us be clear that this role of institutional line management accountability should not be
construed as a return to the old management formula, wherein NASA civil servants
provided oversight for every task performed by the contractor or team. Instead, we
recommend that NASA conduct more rigorous, in-depth reviews of the contractor’s and
the team’s work – something that was lacking on the Mars Climate Orbiter.
To accomplish this, line management should be held accountable for asking the right
questions at meetings and reviews, and getting the right people to those reviews to
uncover mission-critical issues and concerns early in the program. Institutional
management also must be accountable for ensuring that concerns raised in their area of
responsibility are pursued, adequately addressed and closed out.

Line organizations at the field centers also must be responsible for providing robust
mechanisms for training, mentoring, coaching and overseeing their employees, project
managers and other project team leaders. An aggressive mentoring and certification

program should be employed as the first step toward nurturing competent project
managers, systems engineers and mission assurance engineers for future programs.
Line organizations, in conjunction with the projects, also must instill a culture that
encourages all internal and external team members to forcefully and vigorously elevate
concerns as far as necessary to get attention within the organization. Only then will
Mission Success First become a reality.

4) Technology

Technological innovation is a key aspect in making the “Faster, Better, Cheaper”
approach a reality. Through such innovation, smaller, lighter, cheaper, and better-performing
systems can be developed. In addition, innovative processes enable quicker
development cycles. To enable this vision, NASA requires adequately funded
technology development, specifically aimed at Agency needs. Programs and projects
must conduct long-range planning for and champion technology infusions resulting in
delivery of low-risk products for project incorporation.

Mechanisms which minimize technology infusion risk, such as the New Millennium
Program, should be employed to flight-validate high risk technologies prior to their use
on science missions.

Agenda for the Future

The Mars Climate Orbiter Mishap Investigation Board perceives its recommendations as
the first step in an agenda that will be revisited and adjusted on an ongoing basis. The
aim is to make Mission Success First a way of life – a concern and responsibility for
everyone involved in NASA programs.

The recommendations of this report must trigger the first wave of changes in processes
and work habits that will make Mission Success First a reality. To implement this
agenda with a sense of urgency and propagate it throughout the Agency, NASA
Headquarters and the NASA centers must address the recommendations presented in this
report. NASA must further assign responsibility to an organization (such as the Office of
the Chief Engineer) for including the recommendations in Agency policy and in training
courses for program and project management.

These actions will ensure that Mission Success First serves as a beacon to guide NASA
as the future unfolds.