March 23, 2001

TO: A/Administrator

FROM: W/Inspector General

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

  • Full Report, (Acrobat)

    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.


    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


    Final Report on Audit of Space Shuttle Program Management Safety Observations


    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.