Status Report

Prepared Statement by Kevin Carson – Hearing: Oversight Review of the Investigation of the NASA Inspector General

By SpaceRef Editor
June 8, 2007
Filed under ,
Prepared Statement by Kevin Carson – Hearing: Oversight Review of the Investigation of the NASA Inspector General

Mr. Chairmen and Members of the Committees:

Thank you for the opportunity to be here today to discuss my experiences while employed in the NASA Office of Inspector General (OIG).

Since March 2005, I have been employed as the Assistant Inspector General for Audits and Inspections at the U.S. Government Printing Office, Office of Inspector General in Washington, D.C. Previously, I worked over 15 years (August 1989 to March 2005) for the NASA OIG. While with the NASA OIG, I held a variety of audit positions including Deputy Assistant Inspector General for Audits, Director of Audit Quality, and Program Director for Safety and Security Audits. Including my employment with the NASA OIG, I have spent approximately 27 years of my career in various Federal audit organizations.

I have been invited here today to provide testimony related to my time and experience in the NASA OIG while working under the direction of NASA Inspector General Robert Cobb. In order to talk about this time period, I must first discuss my experience with the organization prior to Mr. Cobb’s appointment in April 2002.

NASA OIG Prior to 2002

In early 1999, the previous NASA Inspector General Roberta Gross, upon the NASA Administrator stating that the Agency’s Number One Priority was “Safety,” appointed me to form a directorate whose specific mission was to audit safety and security issues within NASA. While forming the directorate with a small staff of auditors, the directorate quickly performed a series of audits and issued reports addressing various safety issues primarily at NASA’s manned space flight centers. Among the first reports issued by the directorate included:

  • IG-00-028 Safety Concerns with Kennedy Space Center’s Payload Ground Operations, March 30, 2000,
  • IG-00-035 Contractor Safety Requirements at Kennedy Space Center and Marshall Space Flight Center, June 5, 2000,
  • IG-01-017 Space Shuttle Program Management Safety Observations, March 23, 2001,
  • IG-01-034 Controls Over the Use of PFA’s In and Around the Space Shuttle Orbiter Vehicles, August 31, 2001,
  • IG-01-042 Safety of Lifting Devices and Equipment at Stennis Space Center, September 28, 2001,

During the first 2 years the directorate was in existence, we also issued several other reports related to issues such as controls over Foreign National Visitors at NASA Centers, Management and Administration of International Agreements at NASA, and NASA Oversight of Contractor Exports of Controlled Technologies. The directorate was also responsible for audits of classified NASA Programs and Projects.

Some of the highlights of the reports issued included the report on Safety of Lifting Devices and Equipment at Stennis which resulted from a request by the NASA Associate Administrator for Safety and Mission Assurance. The audit identified significant safety issues related to lifting devices and equipment and found that Stennis did not safely perform critical lifts of high-dollar items such as space hardware, one-of-a-kind test articles, major facility components, or personnel. In addition, we found that operators and riggers were not properly trained and certified, operators used cranes with safety deficiencies, and crane maintenance and inspections were inadequate.

At the request of the House Science Committee, we performed an audit of safety related to Kennedy Space Center’s Payload Ground Operations and found that various materials used in processing facilities at the Kennedy Space Center consistently failed required tests for flammability resistance and electrostatic discharge. These potentially hazardous materials included plastic films, foams, and adhesive (PFAs) tapes used by payload processing personnel under the center’s Payload Ground Operations Contract. These materials had been used without approval of the Kennedy Safety Office since 1992. We also found that NASA had not identified, documented, and appropriately mitigated the risks of using these potentially hazardous materials, exposing personnel and flight hardware to increased risks.

On the audit of the United Space Alliance’s (USA’s) safety procedures under NASA’s Space Flight Operations Contract (SFOC), 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) was not providing the required support to the 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; and USA’s reporting to NASA of close calls and mishaps needed improvement. We concluded that NASA did 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 million 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. This report and its results were discussed in the August 2003 Report of the Columbia Accident Investigation Board in Chapter 7, “The Accident’s Organizational Causes.”

We also reviewed USA’s controls over the use of plastic films, foams, and adhesive tapes (PFA’s) used in and around the orbiter vehicles and other segments of the Space Shuttle such as the solid rocket boosters and main engines. We found that USA was routinely using in and around the Space Shuttle orbiter vehicles, PFA’s that had no record of being tested to ensure that the PFA’s met NASA standards for flammability resistance, electrostatic discharge (ESD) rate, or compatibility with rocket fuel. In addition, neither Kennedy Space Center nor USA safety personnel had approved the use of these materials, thereby creating a potential safety hazard to personnel, the orbiter vehicles, and other flight hardware and equipment.

Each of the highlighted reports addressed potentially serious safety issues within NASA and within the manned spaceflight program. I believe that the success of the Safety and Security Directorate was directly attributable to the outstanding professionalism and work ethic of the managers and staff and their collective dedication to the NASA mission. It also helped that the directorate’s work was always supported by then Inspector General Roberta Gross. Although we issued some controversial reports that were not always accepted by the agency, I always felt that the directorate had the complete support of senior OIG management including Ms. Gross. Further highlights from the initial years of the directorate included on two occasions, in 1999 and 2001, the directorate received the OIG Audit Report of the Year Award. One of these reports related to Contractor Safety Requirements and was transmitted by the NASA Administrator to every NASA Center Director, who was directed by the Administrator to implement the recommendations at their respective centers.

In late 2001, I was selected to be the Deputy Assistant Inspector General for Audits. In this position, I had four audit directorates that reported to me including the Safety and Security Directorate. The directorate continued to produce high-value audit products.

April 2002 to March 2005

In April 2002, Robert Cobb was appointed the NASA Inspector General. Although the Office of Audits initially continued to operate as previously, within 3 to 4 months there was a noticeable change. Specifically, there was considerably more involvement in writing, rewriting, and revising audit reports by the Inspector General. There was also considerable questioning of the audit results with Mr. Cobb frequently not agreeing with the conclusions and recommendations in audit reports. There was also what I would say was a general disrespect shown by Mr. Cobb for auditors in particular. Mr. Cobb would often make comments like “anybody can perform an audit” or when an auditor would mention something like compliance with government audit standards, he would make the statement that he had read the government audit standards and that all they were was “something for auditors to hide behind.” He also on more than one occasion mentioned to me that the safety audit directorate had “produced nothing of value to the Agency,” that our audits were “archaeological digs” or that we were “too far in the weeds.”

It was also during this time period that Mr. Cobb appeared to be providing our reports to agency officials for review and comment prior to official draft release in order to determine whether the agency would agree with our findings and recommendations. On one such occasion, a proposed draft audit report on the International Space Station (ISS) was provided to the NASA General Counsel to review prior to official release. The NASA General Counsel did not agree with a conclusion in the report related to the potential for NASA noncompliance with various international agreements on the ISS. Prior to release of the report, the audit team was instructed to remove this section from the report or the report would not be issued.

In instances like the previous one, if any of the senior audit managers were to disagree with Mr. Cobb or try to defend our conclusions and recommendations, we were subject to severe berating and profane language by Mr. Cobb. During these tirades about audits and auditors, I never once saw Mr. Cobb’s Deputy Inspector general ever support the audit staff or the rationale for their conclusions even though they were clearly supported by audit evidence. In fact, Mr. Cobb’s Deputy often made matters worse for the Office of Audits despite having been an auditor himself for many years.

2003 Audit Reorganization

In January 2003, the office of audits was advised by Mr. Cobb that it would be merged with the office of inspections and that all senior management positions in the reorganized office would be moved to NASA Headquarters so that there could be “face-to-face accountability.” Mr. Cobb frequently stated that he wanted these senior managers in Washington so that he could personally “choke them.”

In February 2003, the Office of Audits was merged with the Office of Inspections into the Office of Audits. The new Assistant Inspector General for Audits (AIGA) selected to head up the new organization was the previous Assistant Inspector General for Inspections who had no experience either performing audits or managing any type of audit organization. The previous AIGA was placed in the position of Deputy AIGA.

As part of the reorganization, I was transferred to NASA Headquarters and reverted to my former position as Director of Safety and Security Audits. It was made clear to me by both the new AIGA and his deputy that Mr. Cobb never expected any of the senior managers like me, who were located at field centers, to accept the transfer to Headquarters. The new AIGA even mentioned that Mr. Cobb now had me where he could “choke me.”

After arriving at Headquarters in April 2003, I had even more contact with Mr. Cobb. It was also during this time that the Columbia accident occurred and the invest8igation of its cause had begun. As the Director of Safety and Security Audits, my directorate assumed a large role in directing the work of the OIG related to the recommendations of the Columbia Accident Investigation Board (CAIB) which published its final report and recommendations in August 2003. In response to the CAIB report, I compiled a plan to review the Agency’s implementation of most of the recommendations. In addition, I was authorized to hire additional technical staff to assist with the work to be performed.

It was also during this period, that Mr. Cobb began further interference with the work of the directorate through either constant rewriting of products or attacking the work of the staff and technical experts to the point where findings and recommendations were either never officially issued to the Agency or were issued unofficially by Mr. Cobb to various Agency officials and thus never posted publicly to the NASA OIG website.

CAIB Organizational Recommendations

There are several instances of the stifling or covering up of audit results by Mr. Cobb that I can provide. For example, my staff and I were responsible for reviewing all Agency actions and plans related to the organizational safety recommendations of the CAIB, specifically, (1) the establishment of an Independent Technical Engineering Authority (ITEA), and (2) straight line authority and funding for the Space Shuttle Program safety organization.

On at least three different occasions beginning in December 2003, my staff prepared audit reports basically concluding that NASA was not establishing the ITEA or Space Shuttle Program safety organization in the manner intended by the CAIB. Specifically, we stated that NASA had not fully achieved the reporting and funding independence for either function recommended by the CAIB. We concluded that Technical Warrant Holders-those individuals the NASA Chief Engineer empowered to ensure compliance with technical standards and requirements, lacked independence from major program influences. We further stated that NASA’s plans to strengthen safety functions did not provide for a safety official at the centers to be accountable to the head of safety at NASA Headquarters. Based on the structure the Agency was proposing, we concluded that the individuals ultimately held accountable for ITEA and safety would be subject to cost, schedule, and other pressures from the same program they would be responsible for independently assessing.

Despite drafting three reports with basically this same message over a period of 15 months, Mr. Cobb refused to release any of them. On a couple of occasions, these issues were addressed in either a letter signed by Mr. Cobb or an e-mail sent by Mr. Cobb to selected NASA officials.

On October 6, 2004 during my monthly Directorate briefing, the subject of this review was brought up and Mr. Cobb stated that my staff had spent almost a year reviewing the ITEA and Safety recommendations of the CAIB yet “had nothing to show for it.” When I reminded Mr. Cobb that my staff had prepared three separate audit reports that he chose not to issue, he stated that he was not satisfied with the message of the reports. I defended the work of my staff and stated that the reports were right on the issue and that they should be issued. I subsequently have been told that the current NASA Administrator made several of the organizational changes with safety and the ITEA that we had recommended in our reports despite the fact that they were never issued.

Cape Canaveral Air Station Command Destruct

During October 2004, my Directorate also received a referral from the NASA OIG Office of Investigations concerning a “potential safety issue involving command destruct” at the Eastern Test Range of Cape Canaveral Air Station. The allegation concerned a possible safety violation that occurred in conjunction with a launch of the Space Shuttle in 2002. Specifically, that during the June 5, 2002 launch of the Space Shuttle, the Commander of the Eastern Range overruled the “No-Go” recommendations of the Air Force’s Mission Flight Control Officer (MFCO) and Chief of Safety and proceeded to declare the range “Go” for launch of the Space Shuttle. The reason for the “No-Go” recommendations of the MFCO and Chief of Safety was that there was a failure of the backup Command Destruct System which was not certified as mission capable prior to launch as required. The original allegation had been referred to the NASA OIG by the U.S. Air Force Inspector General in August 2003. After reviewing the allegation for any potential criminal violations, the Office of Investigations referred it to audits and my directorate because of the potential safety issues involved with the allegations.

Upon assigning this issue to a member of my staff, who was an Air Force officer with an extensive safety background, it quickly became apparent that there was substantial merit to the allegation and that the sequence of events, where the Range Commander overruled the MFCO and Chief of Safety and declared the range go for launch despite a less than fully certified Command Destruct System, was unprecedented. To verify that this situation did in fact occur, a total of 9 witnesses were interviewed who were present on console for the launch. We also reviewed various launch-related records. Since the NASA firing room and the range control center are not co-located, the NASA Launch Director and Mission Management Team Chair at the time relied solely on the Go recommendation of the Eastern Range Commander without any NASA independent verification. Both of these individuals also stated that they would not have launched had they known that the Air Force MFCO and Chief of Safety were “No-GO’ for launch.

Upon completion of our preliminary work, my staff and I arranged to brief Mr. Cobb on February 23, 2005 on the results of our review to include the work remaining to complete the review and what our preliminary recommendations to NASA would be. The staff and I had previously met with Safety Officials at Kennedy in January 2005 and had obtained their agreement with our proposed recommendations. We received complete concurrence with our primary recommendation that NASA Safety must positively verify the Eastern Range status and range configuration prior to every launch. At the briefing on February 23, 2005, I was promptly told by Mr. Cobb at the completion of the briefing that this situation “was the Air Force’s problem.” While reporting of this situation would have been controversial to the Agency, it was not a surprise to me that Mr. Cobb would not allow any further work on this assignment to be performed. I am unaware whether this situation concerning launches has ever been addressed or corrected.

Other Instances

While I have discussed the above two instances where my directorate was either interfered with by Mr. Cobb, not allowed to complete work, or not allowed to issue reports, there were numerous other examples of this type of behavior throughout my directorate or throughout the Office of Audits. For example, despite allegations of the possible NASA misuse of funds appropriated by Congress for security at Federal Agencies subsequent to September 11, I was told by the Assistant Inspector General for Audits that Mr. Cobb would not allow an audit of that area because it would only serve as an “archaeological dig” and would be embarrassing to NASA.

In another instance, an audit report was drafted by my Directorate addressing noncompliance at Kennedy Space Center with the Occupational Safety and Health Administration’s (OSHA) Process Safety Management (PSM) standard. The draft report discussed the lack of PSM procedures for the transportation of highly hazardous chemicals via the Kennedy railroad. Specifically, neither the United Space Alliance (USA) nor Space Gateway Services (SGS) had developed PSM procedures for the railroad transportation of space shuttle solid rocket motor segments (which contain ammonium perchlorate) and nitrogen tetroxide (which was transported on behalf of the US Air Force). Neither contractor believed that they were responsible for the PSM program of the railroad and neither believed that the PSM standard applied to Kennedy railroad operations. The report illustrated the need for PSM procedures related to the railroad by discussing several railroad mishaps that had occurred over the previous 3 years. After reviewing the report, Mr. Cobb stated that the report was “based on a flawed premise” and directed that the report be rewritten to address the need for improved oversight and safety procedures for the KSC railroad itself, including inspections and maintenance of the railcars and the track. This direction required additional work by the audit team despite the fact that sufficient work related to the PSM issued had already been performed. Due to the change in direction of the assignment by Mr. Cobb, the OIG was not involved in any further actions related to PSM as it applies to the Kennedy railroad.


In summary, by constantly writing and re-writing audit reports, not allowing audits of potentially controversial issues to be performed or reports of completed audits to be publicly issued, constantly denigrating the audit staff in public and in private, intimidating auditors and staff through the use of verbal threats, foul language and intimidating gestures, Mr. Cobb showed that he lacked independence from Agency officials and was willing to go to any length not to issue audit reports that would embarrass the Agency. In my opinion, he clearly created and endorsed a hostile work environment. Thank you, and I would be pleased to answer any questions.

SpaceRef staff editor.