W October 23, 1997

TO: M/Associate Administrator for Space Flight

FROM: W/Assistant Inspector General for Inspections and Assessments

SUBJECT: Observations and Recommendations Regarding Long-Duration

Astronaut Debrief and Post-Mission Report Processes

The Office of Inspector General (OIG) is conducting an inquiry on U.S.
participation in the Russian Mir Space Station Program. As part of this
inquiry, we examined the Phase I long-duration astronaut debrief and
post-mission report process. We believe that NASA can improve this
process so that astronaut debriefing information is more effectively
shared and utilized in the interests of safety and mission success.
Specifically, we are recommending that NASA: (1) improve the scheduling
and subsequent dissemination of the transcribed version of long-duration
astronauts' debriefings and post-mission reports; and (2) standardize
the recording, storage, and control of debriefing materials.

**[A. Background]{.smallcaps}**

On July 11, 1997, the House Committee on Science requested the NASA OIG
to assess the Agency's participation in the Russian Mir Space Station
Program. Specifically, the OIG was asked to analyze: (1) suitability of
Russia's Mir space station for habitation by U.S. astronauts, (2)
research productivity on-board the Mir, and (3) cost effectiveness of
continued NASA involvement in the Mir Space Station Program. These
issues were preliminarily addressed in the OIG response letter to
Chairman Sensenbrenner on August 29, 1997 (revised September 12, 1997).

The astronauts provide first-hand information on systems and operations
aboard Mir during post-flight debriefings. The debriefings focus on
lessons learned to help with the planning and preparation for, and
support of, future Mir and International Space Station (ISS)
long-duration missions.

During our inquiry, we obtained long-duration astronaut debriefings in
various media: audio and video tapes, summary reports, and transcripts.
Based on our interviews and observations to date, the scheduling,
recording, dissemination, storage, control and use of astronaut

debriefing information can be improved. Although the Agency has certain
debriefing and post-mission report procedures and processes in place,
they are inconsistently implemented and/or inadequately followed to the
detriment of the ISS Program.[^1]

**[B. Need for Timely Scheduling and Wider Dissemination of Astronaut
Debriefings and Post-mission Reports]{.smallcaps}**

1\. [Process]{.underline}

The existing Debrief/Post-Mission Report Process consists of several
steps involving different officials and teams.[^2] Detailed debriefing
schedules are developed for each returning astronaut.[^3] In general,
the returning crew member is provided a list of questions in advance of
the debriefing sessions. The debriefings are informal and may be
recorded with the permission of the crew member. Notes are taken by the
teams and moderator, who then provide a draft report which the crew
member reviews and approves. Copies of debriefings are forwarded to the
Phase 1 Program Office. In addition, the Phase 1 Program Manager and the
Director of Flight Crew Operations also conduct one-on-one debriefing
sessions. However, neither of these two officials reduces their
debriefings to a formal written or taped report for the record.

The debriefing process includes a final post-mission report completed by
the long-duration astronaut. During the drafting of this report, only
one astronaut had completed a final post-mission report. Two
long-duration astronauts had separated from NASA without completing a
final report. Obviously, such a report could offer valuable insights for
safety and mission success if it is timely and is disseminated to the
groups with operational and oversight responsibilities.[^4]

2\. [Dissemination]{.underline}

Existing guidelines call for a subject matter team leader to distribute
the debriefing report to the remainder of the team and the Phase I
Project Office. The guidelines specify that lessons learned and actions
identified in the final post-mission report be reviewed by the Astronaut
Office and the Phase 1 Program Office. This information is then entered
into the "Postflight Crew Recommendation" database for tracking actions
and referrals. The guidelines also stipulate that appropriate actions
will be assigned to NASA organizations to address these issues (See
Appendix A). However, there is no requirement that the lessons learned
be reviewed by Headquarters offices such as the Office of Safety and
Mission Assurance or the Office of Space Flight.

As of the date of this correspondence, only one astronaut's final
debriefing report is in the database. The database, started for the
STS-69 Shuttle mission, is updated quarterly and routinely distributed
to organizations and officials within Johnson Space Center (e.g., Center
Director, Mission Operations Directorate, Phase I Program Office, ISS,
etc.). Contents of the database come from the Shuttle post-flight and
post-mission reports of the astronauts.

The debriefings and final post-mission reports are not routinely
disseminated to the NASA advisory committees (e.g., NASA Advisory
Council and its advisory committees and the NASA Aerospace Safety
Advisory Panel). As specific issues arise, some advisory committees have
contacted astronauts directly or requested debriefing materials.

The Shuttle/Mir Rendezvous/Docking Missions and ISS Operational
Readiness Task Force (known as the Stafford Task Force) is not routinely
included on all long-duration astronaut debriefing distribution lists.
The debriefings contain information which could be useful to them in
their evaluations and recommendations.[^5] For example, during a
debriefing in October 1996,

5 months before the fire on-board Mir in February 1997, an astronaut
discussed fire emergency equipment and drills. The astronaut reported
knowing where the emergency equipment (masks and extinguishers) was
located, and recalled only one drill during the first month in
orbit.[^6] Upon reviewing this debriefing, an outside group applying
appropriately rigorous safety standards may have questioned the adequacy
of fire procedures and drills, raised questions about the availability
and suitability of the fire-fighting equipment, recommended the need for
more fire drills, and specifically asked for details related to the
potential fire hazards. These issues are better raised
[before]{.underline}, not after a life-threatening event.[^7]

Debriefing materials are not centrally located, but are maintained by
the various subject matter teams (e.g., Crew Systems, Operations,
Payloads, ISS, etc.). Thus, there is no single collection point for the
documents, which makes the distribution process far less efficient.

**[Recommendations]{.underline}**. We recommend that the Office of Space
Flight (OSF) monitor the long-duration astronaut post-flight debriefing
process to ensure that: (1) all sessions are scheduled and conducted in
a timely manner, (2) astronaut debriefings are routinely distributed to
key personnel and oversight managers at NASA Headquarters, and (3) the
NASA Advisory Council and other appropriate advisory committees are
routinely provided debriefing reports. (In the case of transcribed
records, summaries, and post-flight recommendations and actions, OSF can
facilitate distribution through electronic mail.) More specifically, we
recommend that:

1.  NASA designate an official to monitor and coordinate the
    long-duration astronaut debriefing process to ensure that all
    required sessions are timely conducted.

2.  All long-duration astronauts timely complete the final post-mission
    report.[^8]

3.  At a minimum, long-duration astronaut debriefing materials be
    routinely distributed, as soon as they are finalized, to the Office
    of Space Flight, the Office of Safety & Mission Assurance, and the
    Office of Life & Microgravity Sciences and Applications. Further,
    appropriate NASA advisory committees, panels, and independent
    assessment teams (e.g., the NASA Advisory Council, the NASA
    Aerospace Safety Advisory Panel, the Advisory Committee on the
    International Space Station, and the Stafford Task Force) should
    routinely receive debriefing reports from the long-duration
    astronauts as part of their safety and scientific advisory
    responsibilities. (The committees and panels can follow-up
    individually and on a confidential basis, if necessary, regarding
    matters about which they want more information.)

4.  The "Postflight Crew Recommendation" electronic database should be
    routinely updated as long-duration astronaut debriefings are
    completed. The updated database should be transmitted to the
    organizations listed in Recommendation 3 above.

5.  A central repository should be established for long-duration
    astronaut debriefing materials. A detailed and accurate record of
    distribution be maintained to account for all routine distributions
    of and special requests for long-duration astronaut debriefing
    materials.

**[C. Recording, Storage & Control of Debriefing
Materials]{.smallcaps}**

NASA uses several different approaches to memorialize debriefings. Some
debriefing teams audio or video tape sessions without preparing
transcripts. Other teams summarize debriefing sessions based on notes.
Standardizing the debriefing formats by requiring both transcripts of
audio or video tapes and written summaries will facilitate simultaneous
analysis by diverse groups. In this way, immediate safety and mission
issues will be disseminated in a comprehensive manner and future actions
can be assigned.

We recognize that astronauts may discuss highly sensitive information
for which dissemination should be more restricted. For example,
astronauts may discuss their medical conditions. They may also want to
discuss opinions about crew or ground performance (e.g., negligence or
misconduct). These communications, too, generally should be reduced to a
written report because of their importance to evaluators (e.g., doctors,
safety specialists, etc.). NASA may wish to restrict the dissemination
of these reports. Restrictions should be clearly marked on the report
(e.g., Privacy Act warnings) and these documents maintained separately
in accordance with prudent physical security procedures. At present,
NASA has no comprehensive policy and procedures regarding the
dissemination of sensitive debriefing materials.[^9]

**[Recommendations]{.underline}**. We recommend that the Office of Space
Flight review the long-duration astronaut debriefing process to ensure
that effective recording and transcribing procedures are applied for all
sessions with special precautions taken for highly sensitive
information. Specifically, we recommend that:

1.  All long-duration astronaut sessions be audio or video taped. The
    tapes should be timely transcribed and summary reports prepared.

2.  Tapes and transcripts should be maintained, accessed, labeled, and
    stored in a central repository in accordance with prudent physical
    security procedures, except for restricted information. A listing of
    restricted documents and their location should also be maintained in
    the central repository. Copies of materials retained by debriefing
    teams or other organizations should be stored in the same manner as
    materials in the central repository.

3.  NASA should ensure that those responsible for the debrief materials
    are well versed in the policies and controls regarding the
    restrictions for dissemination of the materials such as medical and
    privacy act restrictions.

**[D. Summary & Evaluation of NASA Management's Response]{.smallcaps}**

We received NASA's response to our draft report on October 21, 1997 (See
Appendix C). The response stated that the "report is accurate and makes
sound recommendations." However, the Agency took exception to:

1.  [Section B, Recommendation 1, page 4]{.underline}. This
    recommendation states "NASA designate an official to monitor and
    coordinate the long-duration astronaut debriefing process to ensure
    that all required sessions are timely conducted." The Agency
    responded that the debriefing schedule process is very controlled
    and considers the health and rehabilitation of the returning
    astronaut as top priority. However, our recommendation stands
    because we believe that the process can be improved by someone
    responsible not only for ensuring that debriefings are scheduled,
    but also actually conducted, documented, and distributed to a wide
    range of cognizant officials and groups in a timely manner. This
    multi-step process can be managed without impacting the health of
    recovering astronauts.

2.  [Section C, Recommendation 1, page 5]{.underline}. NASA also took
    exception with our recommendation to tape and transcribe debriefing
    sessions, indicating that a "final report should be much shorter,
    easier to read, and focus on the real substance of the debrief." We
    have no objection to summaries of debriefing sessions; such
    summaries can satisfy some information needs. However, we believe
    that tapes and fully transcribed accounts provide the detail and
    insight required for thorough safety and program evaluation. Our
    recommendation stands as originally stated.

3.  [Section C, Recommendation 3, page 6]{.underline}. The Agency
    suggested alternative language regarding this recommendation
    concerning restrictions on the dissemination of astronaut
    communications to reflect controls now in effect. We have accepted
    their suggested language and amended our recommendation accordingly.

We have indications that the Agency has moved to improve its debriefing
and post-mission reporting processes. We will continue to review the
process and evaluate the application of the recommended changes.

**[Conclusion]{.underline}**

The lessons learned from the experiences, observations, and impressions
of our long-duration astronauts are vital in ensuring safety and
productivity in the development of the ISS. A principal way to surface
these lessons learned is through wide and timely distribution of
debriefing materials. This information should be reviewed by all
involved in the development and operation of the ISS, including those at
Headquarters providing oversight. NASA has traditionally turned to
non-government sources for independent judgment and guidance, including
its own NASA Advisory Council. In keeping with this oversight mechanism,
the appropriate advisory committees also should routinely review the
astronaut debriefing materials. We believe the recommendations we have
made will enhance ISS safety and mission success.

David M. Cushing

Enclosures

cc:

Distribution

bcc:

AIGIA Chron

Mellerio Chron

IG Chron

**Distribution**

**[National Aeronautics and Space Administration (NASA)
Officials-In-Charge]{.underline}**

A/Administrator

AD/Acting Deputy Administrator

AT/Associate Deputy Administrator (Technical)

G/General Counsel

J/Associate Administrator for Management Systems and Facilities

L/Associate Administrator for Legislative Affairs

M/Associate Administrator for Space Flight

P/Associate Administrator for Public Affairs

Q/Associate Administrator for Safety and Mission Assurance

U/Associate Administrator for Life & Microgravity Sciences &
Applications

Z/Associate Administrator for Policy and Plans

Director, Johnson Space Center

**[NASA Advisory Council Officials]{.underline}**

Chairman, NASA Advisory Committee

Chairman, NASA Aerospace Advisory Council

Chairman, Advisory Committee on the International Space Station

Chairman, Shuttle/Mir Rendezvous/Docking Missions and ISS Operational
Readiness Task Forces

**[Chairman and Ranking Minority Member of each of the following
Congressional Committees and Subcommittees:]{.underline}**

Senate Committee on Appropriations

Senate Subcommittee on VA-HUD-Independent Agencies

Senate Committee on Commerce, Science and Transportation

Senate Subcommittee on Science, Technology and Space

Senate Committee on Governmental Affairs

House Committee on Appropriations

House Subcommittee on VA-HUD-Independent Agencies

House Committee on Government Reform and Oversight

House Subcommittee on National Security, International Affairs, and
Criminal Justice

House Committee on Science

House Subcommittee on Space and Aeronautics

**APPENDIX A\
**

For copies of the graphic appendices, contact Dana M. Mellerio, (202)
358-0271

[^1]: In September 1977, the Inspector General (IG) communicated to the
    NASA Administrator general concerns about astronaut communications,
    including the debriefing process. The Administrator indicated he
    will promptly followup in the area of astronaut communications. The
    IG also indicated to the Young Task Force (Mr. A. Thomas Young, Mr.
    Laurence J. Adams, Major General Charles F. Bolden, Jr.,

    Ms. Barbara Corn) that the OIG would be doing followup regarding the
    debriefing process. (The Young Task Force was assembled at the
    request of the NASA Administrator to review the OIG response letter
    to the Honorable F. James Sensenbrenner, Chair, House Committee on
    Science).

[^2]: See Appendix A, Crew Exchange and Training Working Group, Debrief
    and Post-Mission Report Process, May 2, 1997.

[^3]: ^?^ See Appendix B, Breakout of Generic LDM Crew Post Flight
    Schedule and STS-84 Crew Activity Schedule.

[^4]: The usefulness of a final report by a long-duration astronaut is
    apparent from looking at the one prepared by Shannon Lucid. She
    included some key recommendations which generally have been adopted
    in areas such as organizing daily on-flight activities, family
    support during flight, post-flight activities, etc. She also made a
    key observation which deserves more study: crew capability (". . . I
    think this is the most important aspect of a long-duration flight. .
    .").

[^5]: The Young Task Force specifically stated in their recommendations
    that ". . . the safety and mission success inputs of the U.S.
    astronauts who have flown as Mir crew members need to be included as
    a part of the review process for critical Shuttle/Mir functions and
    as critical inputs to the development process for the International
    Space Station. We believe the Mir related part of this
    recommendation needs to be implemented prior to the transfer of the
    next American astronaut to Mir on STS-86."

[^6]: ^?^ Astronaut's Debrief dated October 15, 1996:

    **Q: Do you feel the emergency equipment; fire extinguishers,
    breathing masks, small portable lights, etc., were supplied for you
    in sufficient numbers?**

    A: The emergency equipment was there and I knew where it was. I
    always carried my flashlight with me because if we lost power, I
    would obviously want a flashlight.

    **Q: Do you have any suggestions for additional equipment along the
    categories of emergency equipment or contingency equipment that you
    thought was lacking or that you would like to see added?**

    A: We had masks. If there was a fire, we had fire extinguishers, but
    I'm used to seeing fire extinguishers in red rather than the Russian
    gray or blue fire extinguishers. They do not stand out visually. Red
    would be a better color. Visually speaking, if it stands out more,
    then it is easier to pick out in an emergency.

    **Q: Did you have training drills, evacuation drills, or safety
    training while you were on Mir?**

    A: Once, during the first month. The ground set aside a block of
    time where we discussed getting in the Soyuz, and what we would do
    if there was a fire or if we became unpressurized. We spent a few
    hours discussing that and looking into what we would do.

[^7]: During February 1997, astronaut Linenger reported he had been
    unable to get oxygen from the first gas mask he attempted to use;
    clamps designed to keep the fire extinguishers in place had not been
    removed so that the crew had to get tools to remove the clamps
    before they could attempt to extinguish the fire.

    As a result of the fire, and other incidents, a joint U.S./Russian
    safety assurance working group met (August 25- September 5, 1997).
    They recommended, among other matters, that the crew follow safety
    measures, including wearing gloves when igniting the canisters,
    having fire extinguishers and gas masks immediately available, and
    monitoring cassette initiation. On September 24, 1997, the Stafford
    Task Force Red Team recommended: "If not currently practiced,
    regular reviews of fire procedures (i.e., fire drills) should be
    instituted."

[^8]: During the drafting of this report, a second long-duration
    astronaut submitted a "final report" weeks after separating from
    NASA and almost 8 months after returning from Mir. More timely
    submissions will be more valuable to mission safety and assurance.

[^9]: NASA obviously applies the Privacy Act and FOIA to data, as
    applicable (e.g., medical information). Nevertheless, there is no
    general policy regarding the dissemination of long-duration
    astronaut debriefing post-flight materials.