Update on NASA's Quality System

Interesting. During the recent trip of the space shuttle, there were constant updates from NASA on the investigation of detached foam. This was a dire situation. It happened before and the consequences were lethal. It happened again during take off and there was question as to whether the astronauts would safely return to Earth.

Well, they did and we have not heard much from NASA since. At least I have not heard or read much about NASA's investigation into the "loose foam".

In today's paper there was an article on page 6A. Tucked away in a 2 x 2.5 inch space of the upper right corner, the title read Tiled Repairs contributed to shuttle's foam loss. The article gives what appears to be a root cause statement.

The first sentence: "Inadequate methods of applying and repairing foam on the space shuttle's fuel tank probably contributed to the dangerous loss of a chunk of the insulation during Discovery's launch 2 1/2 months ago." This was the conclusion of a NASA investigation team.

Now I believe that solving a quality problem on a space shuttle is difficult. There are thousands of parts and as many interactions between parts. But NASA hires engineers (or should hire) based on their abilities to work with such complex systems. Plus, NASA must have problem solving processes commensurate with the complexity of the product.

Such a probable root cause statement smells like the often used operator error root cause. It's not the operator's fault. It's the process being used and/or the system that the process belongs to.

Just ask the five whys to NASA's statement: Why were the methods inadequate? You are off and running.