Space Shuttle Program Management Safety Observations Report Number IG-01-017

The NASA Office of Inspector General (OIG) is performing an audit of the United Space
Alliance’s (USA’s) safety procedures under NASA’s Space Flight Operations Contract
(SFOC).¹ As part of the audit, we reviewed the oversight of USA’s safety procedures for the
Space Shuttle Program at the Lyndon B. Johnson Space Center (Johnson). We found that the
Johnson Safety, Reliability, and Quality Assurance Office (Johnson Safety Office) is not
providing the required support to the Manager, Space Shuttle Program Safety and Mission
Assurance (Space Shuttle Program Safety Manager), for oversight of USA’s safety activities.
We also found that NASA’s contractor surveillance plans do not address all SFOC
requirements for safety; USA did not update its Management Plan to reflect organizational and
personnel changes to the SFOC, including changes in key safety personnel from NASA and
USA; and USA’s reporting to NASA of close calls² and mishaps needs improvement. As a
result, NASA does not have adequate management controls in place to ensure (1) effective oversight of USA’s safety operations under the SFOC,
(2) better control over $13 million³ in annual Space Shuttle Program funds provided to the
Johnson Safety Office, and (3) that adequate corrective actions are taken on all safety mishaps
and close calls. We have addressed safety involving NASA contractors in two prior audit
reports.⁴ A synopsis of each report is in Appendix B of the attached report.

Background

The SFOC and the SFOC Contracting Officer impose many safety requirements on USA and
NASA. The NASA Space Transportation System (NSTS) 07700 5 requires that the Johnson
Safety office support the Space Shuttle Program Safety Manager. Also, the Contracting Officer
requires each Technical Management Representative (TMR)⁶ to develop a surveillance plan that
includes providing input to the Space Shuttle Program Safety Manager regarding safety issues in
each of the TMR’s delegated areas of responsibility. In addition, the SFOC requires USA to
establish and maintain a Management Plan that includes current procedures for management of
USA’s safety program under SFOC. Finally, the Agency requires that all NASA reportable
mishaps and close calls (including those incurred by contractors) be recorded and submitted
electronically to the Agencywide reporting system.⁷ Prompt management attention to these
areas is particularly important to the continued success of the Space Shuttle Program as it
prepares to increase the number of flights in the next year.⁸

Management Response and OIG Evaluation

While management did not agree with all of the findings, Johnson concurred with the
recommendations and has planned or taken responsive corrective actions. Johnson will
establish procedures to clarify the responsibilities of the Johnson Safety Office to ensure that it
provides the necessary support to the Space Shuttle Program Safety Manager. Johnson also
plans to update the various SFOC surveillance plans to adequately address safety, revise the
SFOC Management Plan to reflect current operations, and ensure that the Agency’s automated
mishap tracking system accurately reflects current USA mishap and close call information.
Details on the status of the recommendations are in the report’s recommendation section.

[original signed by]

Roberta L. Gross

Enclosure

Final Report on Audit of Space Shuttle Program Management Safety Observations

Notes:

¹ NASA awarded the SFOC to USA of Houston, Texas, on September 26, 1996. USA is a joint venture of The Boeing
Company and Lockheed-Martin to conduct the SFOC and is the prime contractor for NASA’s Space Shuttle Program.
USA performs work for SFOC under contract number NAS9-20000. The total contract cost plus fee is estimated at
$8.6 billion. The contract is a cost-plus-award-fee/incentive fee/performance fee type contract and has a period-of-performance
of October 1, 1996, through September 30, 2002. The contract includes two, 2-year option periods, which
potentially extend the period-of-performance through September 30, 2006.

² NASA Procedures and Guidelines (NPG) 8621.1, “NASA Procedures and Guidelines for Mishap Reporting,
Investigating, and Recordkeeping,” June 2, 2000, defines a close call as a situation or occurrence with no injury, no
damage or only minor damage (less than $1,000), but has the potential to cause any type mishap, or any injury, damage,
or negative mission impact. (A close call is not considered a mishap, but the mishap reporting, investigation, and
recordkeeping and recurrence control guidelines will be followed).

³ Johnson Space Shuttle Program management provided us this funding amount. The Johnson Space Shuttle Program
Business Management Office could not provide us documentation to support the amount. This funding flows down to
the Johnson Safety Office, Shuttle Division from the various Space Shuttle Program components (Orbiter, External
Tank, Space Shuttle Main Engine). From a total of $16 million, $3 million was for the Johnson Institutional Safety
Office. The Johnson Safety Space Shuttle Division consists of 22 civil servants and 120 contractor support staff.

⁴ The two reports that address safety issues with NASA contractors are Report No. IG-00-035, “Contract Safety
Requirements at Kennedy Space Center and Marshall Space Flight Center,” June 5, 2000, and IG

Concerns with Kennedy Space Center’s Payload Ground Operations,” March 30, 2000.

⁵ SFOC Section J-1-A, paragraph 1 imposes the NSTS 07700 series of documents, “Space Shuttle Program
Requirements and Description.” The latest revision of NSTS 07700, Revision G, was dated December 17, 1997.

⁶ The Contracting Officer delegates management of each major component of the Space Shuttle Program to the TMR’s.
The major components are (1) Space Shuttle Program Systems Integration, (2) Safety and Mission Assurance, (3) Space
Shuttle Program Management Integration, (4) Avionics and Software, (5) Flight Crew Operations, (6) Mission
Operations, (7) Space Shuttle Vehicle Engineering, (8) Space Station Office, (9) Solid Rocket Booster Project, (10)
Logistic Operations, and (11) Shuttle Process Integration.

⁷ The Incident Reporting Information System (IRIS) is NASA’s Agencywide automated system for tracking mishap
and injury information. The IRIS enables the real-time reporting of mishaps and injuries and facilitates detailed mishap
investigation and follow-up documentation. The IRIS provides a valuable tool for reporting mishap information to
NASA management and outside sources and is the Agency’s primary system for accumulating data on employee injuries
and lost time rates.

⁸ From October 2000 through September 2001, NASA has planned nine Space Shuttle flights to assemble the
International Space Station. From 1996 through 2000, NASA averaged five flights per year.