IG-00-028

AUDIT

REPORT SAFETY CONCERNS WITH

KENNEDY SPACE CENTER’S

PAYLOAD GROUND OPERATIONS

March 30, 2000

National Aeronautics

and

Space Administration

OFFICE OF INSPECTOR GENERAL
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Acronyms

CMR Center Materials Representative

ESD Electrostatic discharge

ISS International Space Station

MUA Material Usage Agreement

O&C Operations and Checkout

OIG Office of Inspector General

PFA Plastic film, Foams, and Adhesive tapes

PGOC Payload Ground Operations Contract

SSPF Space Station Processing Facility
W March 30, 2000

TO: A/Administrator

FROM: W/Inspector General

SUBJECT: INFORMATION: Safety Concerns with Kennedy Space Center’s

Payload Ground Operations Redacted Report∗

Report Number IG-00-028

The NASA Office of Inspector General has completed an audit of Safety Concerns with Kennedy

Space Center’s Payload Ground Operations. During the audit, we found materials that consistently

failed required tests for flammability resistance and electrostatic discharge1 in use in two processing

facilities at the Kennedy Space Center. Such potentially hazardous materials include plastic films,

foams, and adhesive tapes used by payload processing personnel under Boeing’s Payload Ground

Operations Contract. These materials have been used without approval of the Kennedy Safety Office

since 1992. NASA authorized variances,2 in the form of Materials Usage Agreements,3 for the use of

some of the materials but not until 1999. However, the contractor continued unapproved uses of the

materials even under the terms of the Materials Usage Agreements. Moreover the variances were

ineffective because neither the NASA nor Boeing safety offices reviewed the variances and Boeing had

not performed required risk analyses to support the variances. As a result, NASA has not identified,

 

*We have redacted portions of this report due to deliberative process information. The redacted passages do not

affect the validity of this report or management's response.

1

 Kennedy Handbook 1710.2, “Kennedy Space Center Safety Practices Handbook,” requires that plastic films and

adhesive tapes pass acceptance criteria for flammability and ESD. The handbook makes reference to the Kennedy

Materials Sciences division intranet, which also includes foams as materials that need to pass the acceptance criteria.

The basic requirements are:

Flammability Resistance – the material should be self-extinguishing before 6 inches of the test sample is

consumed, should not drip flaming particles, and should not permit fire to propagate to another object; and

Electrostatic Discharge – the material can hold a charge of only 350 volts for less than 5 seconds after

termination of the initial charge.

2

 NASA Handbook 1700.1, “NASA Safety Policy and Requirements Document,” defines a variance as documented

and approved permission to perform some act contrary to established requirements.

3

 Material Usage Agreements are Kennedy’s variance mechanisms for allowing the use of materials that fail required

tests for flammability and electrostatic discharge. Scant criteria exist that address the use of Material Usage

Agreements.
documented, and appropriately mitigated the risks of using the potentially hazardous materials, exposing

personnel and flight hardware to increased risks.
2

Background

As Kennedy's Payload Ground Operations contractor, Boeing performs payload-processing activities

for Space Shuttle and expendable launch vehicle payloads, including flight elements of the International

Space Station. Boeing performs such work primarily at two Kennedy Space Center processing

facilities: the Space Station Processing Facility and the Operations and Checkout building.4 Safety is a

critical element of contractor performance. A single mishap could adversely affect flight or key

processing milestones or result in risks to NASA equipment, flight hardware, and personnel. The

Payload Ground Operations Contract requires that all plastic films, foams, and adhesive tapes meet

basic standards for flammability resistance and electrostatic discharge. Processing personnel can use

materials that do not pass required tests; however, NASA and Boeing should prepare a variance for the

use of such materials. To ensure that the associated risks are properly managed, variances should

include appropriate risk mitigation plans. NASA and Boeing safety officials should also review the

variances.

Recommendations, Management's Response, and Evaluation of Response

We recommended that the Director, John F. Kennedy Space Center (1) implement procedures to

ensure the safe use of all materials that do not meet standards, (2) clarify instructions for preparing

Material Usage Agreements,and (3) increase surveillance of Boeing’s inspection procedures. We also

recommended that the Payload Ground Operations Contract Contracting Officer (1) determine whether

there is a basis to withhold contract costs related to noncompliant plastics, foams, and adhesives, and

(2) ensure that proper contract award fee action is taken based on Kennedy’s increased surveillance of

the Payload Ground Operations contractor.

Management concurred with the recommendations. Kennedy has planned or implemented additional

procedures to ensure the safe use of materials that do not meet standards for flammability and

electrostatic discharge. The Center has also agreed to clarify the procedures for preparing Material

Usage Agreements and to increase surveillance of the Payload Ground Operations contractor. Details

on the status of the recommendations are in the recommendations section of the report (pages 9-10).

Kennedy management provided extensive comments on our findings (see Appendix E).

 

4

 The Space Station Processing Facility was built for processing International Space Station flight hardware. It is a

three-story, 457,000 square foot building that includes two processing bays, an airlock, operational control rooms,

laboratories, office space, and a cafeteria. The Operations and Checkout building is used for receiving, assembling,

and integrating Shuttle payloads. It is a five-story building containing 600,00 square feet of offices, laboratories,

astronaut crew quarters, and spacecraft assembly areas.
3

Management contends that plastics, foams, and adhesives are not inherently hazardous materials but can

create potentially hazardous conditions if not properly handled. Our concerns address the weakness in

Kennedy's process for verifying the acceptablility of materials that failed required tests. We respond to

management's comments in Appendix F of the report.

[original signed by]

Roberta L. Gross

Enclosure

Final Report on Audit of Safety Concerns with Kennedy Space Center’s

 Payload Ground Operations
FINAL REPORT

AUDIT OF SAFETY CONCERNS WITH

KENNEDY SPACE CENTER’S

PAYLOAD GROUND OPERATIONS
W March 30, 2000

TO: Q/Associate Administrator for Safety and Mission Assurance

AA/Director, John F. Kennedy Space Center

FROM: W/Assistant Inspector General for Auditing

SUBJECT: Final Report on Audit of Safety Concerns with Kennedy Space Center’s

Payload Ground Operations

Assignment Number A9900301

Report Number IG-00-028

The subject final report is provided for your information and use. Our evaluation of your

response is incorporated into the body of the report. The corrective actions planned for the

recommendations are responsive. Recommendation 4 is considered closed for reporting

purposes. Recommendations 1, 2, 3, and 5 will remain open for reporting purposes until

corrective actions are completed. Please notify us when action has been completed on the

recommendations, including the extent of testing performed to ensure corrective actions are

effective.

If you have questions concerning the report, please contact Mr. Kevin J. Carson, Program

Director, Safety and Technology Audits, at (301) 286-0498, or Mr. Karl M. Allen, Auditor-inCharge, at (202) 358-2595. We appreciate the courtesies extended to the audit staff. The final

report distribution is in Appendix G.

[Original signed by]

Russell A. Rau

Enclosure
2

cc:

B/Chief Financial Officer

B/Comptroller

BF/Director, Financial Management Division

G/General Counsel

JM/Director, Management Assessment Division

M/Associate Administrator, Office of Space Flight

QS/Director, Safety and Risk Management Division
3

bcc:

AIGA, IG Chrons

KSC/201/Audit Liaison Officer

KSC/300/Director, Office of Safety and Mission Assurance

KSC/OP-OSO/Contracting Officer, Payload Ground Operations Contract

W/K. Carson

 K. Allen

 R. Andrade
NASA Office of Inspector General

IG-00-028 March 30, 2000

 A9900301 

Safety Concerns with Kennedy Space Center’s

Payload Ground Operations

Introduction

The Office of Inspector General (OIG) is performing an audit of NASA contractor safety

programs. The overall objective is to evaluate the safety procedures of Agency contractors. As

part of this assignment, we also addressed concerns the House of Representatives Committee on

Science provided to the OIG. The Committee’s concerns focused on the safety functions of the

John F. Kennedy Space Center’s (Kennedy) Payload Ground Operations Contract (PGOC)

performed by McDonnell Douglas Aerospace, Space and Defense Systems; a subsidiary of The

Boeing Company (Boeing). We reviewed the PGOC contractor’s operations to determine

whether:

• safety responsibilities between Boeing and NASA had been clearly defined,

• hazardous materials were being used in Kennedy’s processing facilities, and

• hazardous materials, if used, were properly controlled.

A January 1997 modification to the PGOC (number NAS10-11400) defines Boeing’s safety

responsibilities relating to the PGOC. With this modification, NASA converted the contract to a

performance-based contract and revised the statement of work to more clearly establish safety

responsibilities for Boeing, NASA, and other contractors at various Kennedy processing facilities,

including the Space Station Processing Facility (SSPF) and the Operations and Checkout (O&C)

building.5

Appendix A contains further details on the audit objectives, scope, and methodology.

 

5

 The SSPF was built for processing International Space Station flight hardware. It is a three-story, 457,000

square foot building that includes two processing bays, an airlock, operational control rooms, laboratories,

office space, and a cafeteria. The O&C building is used for receiving, assembling and integrating Shuttle

payloads. It is a five-story building containing 600,00 square feet of offices, laboratories, astronaut crew

quarters, and spacecraft assembly areas.
2

Results in Brief

Ground workers6 at Kennedy were using potentially hazardous materials in both the SSPF and

O&C building that consistently failed required tests for flammability resistance and electrostatic

discharge (ESD). This occurred because Boeing’s safety office did not perform adequate,

contract-required inspections of the facilities to ensure that NASA had approved all plastic films,

foams, and adhesive tapes (PFA’s) being used or that ground workers removed unapproved

materials from the premises. NASA records show that the materials failed required tests as far

back as July 1992. Beginning in September 1999, NASA authorized variances7 for the use of

some of the materials. However, these variances were ineffective because neither the Kennedy

nor Boeing safety offices reviewed the variances, and Boeing did not perform any risk analyses to

support the variances, as required by the PGOC. As a result, NASA has not identified,

documented, and appropriately mitigated the risks of using the potentially hazardous materials,

exposing ground workers and flight hardware to increased risks. NASA and Boeing Safety and

Materials personnel met in December 1999 and acknowledged that problems exist regarding the

use of potentially hazardous materials in both the SSPF and O&C building.

Background

NASA awarded the PGOC to McDonnell Douglas Astronautics Company on

January 1, 1987. The cost-plus-award-fee contract was valued at $1.9 billion and had a period

of performance extending through December 2001. Through a subsequent merger with The

Boeing Company, the contractor became McDonnell Douglas Aerospace, Space and Defense

Systems; a subsidiary of Boeing. As the PGOC contractor, Boeing performs payload-processing

activities for Space Shuttle and expendable launch vehicle payloads, including flight elements of

the International Space Station (ISS). Boeing performs such work primarily at Kennedy in the

SSPF and O&C building. Safety is a critical element of contractor performance. A single mishap

could adversely affect flight or key processing milestones or result in risks to NASA equipment,

flight hardware, and ground workers. According to the PGOC, Boeing is responsible for

ensuring industrial and operational safety8 in most areas of the SSPF and the O&C building. This

includes inspections of all work areas to detect, eliminate, and control hazards. Also, the

Kennedy safety office provides insight into Boeing’s operations.

 

6

 Ground workers include personnel from NASA-Kennedy, Boeing PGOC, Boeing Space Station Contract, and

other contractor personnel authorized to work on payloads in the SSPF and O&C building.

7

 NASA Handbook 1700.1, “NASA Safety Policy and Requirements Document,” defines a variance as

documented and approved permission to perform some act contrary to established requirements.

8

 According to the Boeing PGOC Safety and Health Plan, industrial safety includes safety procedures such as

mishap reporting, facilities design, fire prevention, handling of hazardous materials, and personal protective

equipment. The plan defines operational safety as the development of safety support into payload handling,

testing, and checkout operations processes.
3

The PGOC, by reference to several sources, requires that all PFA’s used in Kennedy processing

facilities meet standards for flammability resistance and ESD.9 At Kennedy, the NASA Materials

Sciences Lab is responsible for testing all materials against flammability and ESD requirements.

NASA and Boeing personnel can use materials that do not pass required tests; however, NASA

and Boeing should prepare a variance for the use of such materials and ensure that the associated

risks are properly managed.

Use of Potentially Hazardous Materials in Kennedy Processing

Facilities

Finding. Ground workers were using potentially hazardous materials in Kennedy processing

facilities without exercising proper control and safety precautions. This condition exists because

(1) Boeing safety personnel have not performed adequate, contract-required inspections of the

facilities and (2) Kennedy or Boeing safety personnel had not reviewed the Materials Usage

Agreements (MUA’s) authorizing use of the potentially hazardous materials, which were not

supported by risk analyses. As a result, NASA lacks assurance that associated risks are

adequately identified, documented, reviewed, and mitigated. Improper use of these materials is

potentially hazardous to ground workers and increases the risk of damage to Space Shuttle

payloads, including ISS hardware and equipment.

Materials Usage Requirements

There are numerous NASA-wide and Kennedy-specific requirements that address the testing and

control of potentially hazardous materials. Appendix B lists the sources of such requirements.

Kennedy Handbook 1710.2, “Kennedy Space Center Safety Practices Handbook,” which is

incorporated into the PGOC by reference and which refers to the Kennedy Materials Sciences

Division intranet, requires that PFA’s pass acceptance criteria for flammability and ESD. The

Kennedy Materials Application Advisory Board maintains a list of the materials that have passed

the required tests and are approved for use in Kennedy facilities. The PGOC Safety and Health

Plan, which is also part of the contract, addresses the procedures for authorizing the use of

materials that do not pass such criteria. Section 3.13 of the PGOC Safety and Health Plan states:

The need for a variance to a safety requirement normally results from a

situation where standard safety precautions and regulations do not permit

accomplishment of, or unacceptably delay, a particular mission or

 

9

 Kennedy Handbook 1710.2, “Kennedy Space Center Safety Practices Handbook,” requires that plastic films,

and adhesive tapes pass acceptance criteria for flammability and ESD. The handbook makes reference to the

Kennedy Materials Sciences division intranet, which also includes foams as materials that need to pass the

acceptance criteria. The basic requirements are:

Flammability Resistance – the material should be self-extinguishing before 6 inches of the test sample is

consumed, should not drip flaming particles, and should not permit fire to propagate to another object;

and

ESD – the material can hold a charge of only 350 volts for less than 5 seconds after termination of the

initial charge.
4

operation. . . . All out-of-family safety variances will be forwarded to

NASA-KSC [Kennedy] Safety for approval. . . . For safety variances

forwarded to NASA Safety for approval, [Boeing] Safety will prepare a risk

assessment of the safety impact of the variance and forward with the

request to NASA-KSC [Kennedy] Safety. . . .

Kennedy uses MUA’s as the variance mechanism for potentially hazardous materials. Scant

criteria exist that address the use of MUA’s other than KSC (Kennedy Space Center)-LO8060.1, “KSC [Kennedy Space Center] Materials and Processes Control Program,” July 15,

1997, which states:

The Directors of Engineering Development; Shuttle Management and

Operations; Payload Management and Operations; Installation

Management and Operations; Safety and Mission Assurance; and the

cognizant program/project manager are responsible for: . . . Ensuring that

only approved M&P [materials and processes] are used (including

contractor usage) and that MUA’s are provided to the CMR [Center

Materials Representative] in a timely manner for evaluation prior to

operations use.

Potentially Hazardous Materials Used

In the SSPF and O&C building, Kennedy ground workers are using the following materials that

have failed the required tests:

• Polyethylene foams are used to pad pieces of flight hardware and test stands and to protect

pallets and flooring surfaces.

• Plastic bubble wrap that often comes into the facilities as packing materials is used.

Photographs from the Kennedy archives of the SSPF high bay showed bubble wrap used for

other than packing material (Appendix D, Figure 3).

• Flash breaker tape is on ISS lab flight hardware surfaces in the SSPF.

We obtained NASA test records, dating from 1992 through September 1999, that show these

materials have failed required flammability and ESD tests, making them noncompliant with the

Space Shuttle Payload Ground Safety Handbook and other Kennedy safety requirements. In

September 1999, the Kennedy Center Materials Representative (CMR)10 approved the use of

some of the materials by signing MUA’s. A full description of the materials, test results, and

MUA data is provided in Appendix C.

We also obtained a list of 73 other PFA’s from the Kennedy Materials Sciences Lab that were

not on the Kennedy-approved material listing and that Boeing may have been using under the

PGOC in the SSPF. These materials were various types of plastic tape, electrical tape, and

 

10 The CMR is responsible for administering Kennedy’s materials and processes control program.
5

plastic bags that may have been used throughout the SSPF. An employee of the Materials

Sciences Lab told us that he instructed the Boeing safety office to have all the materials tested;

however, Boeing never complied with the request. There were no MUA’s for any of these

materials. We could not identify the extent of use of the materials through either our visual

inspections of the SSPF and O&C building, or through pictures from those facilities.

Boeing Safety Inspections

The Boeing safety office has not performed adequate, contract-required inspections of the SSPF

and O&C building. The PGOC Safety and Health Plan, which is incorporated as part of the

contract, states:

Safety inspections of all work areas (payload processing and

administrative) under the jurisdiction of the PGOC will be performed on a

regular basis . . . . The primary reasons for performing safety inspections

are detection, elimination or control of hazards in the workplace, and the

assurance that compliance requirements are being met.

Boeing safety personnel told us they performed regular inspections of both the SSPF and O&C

building high bay areas. However, the effectiveness of those inspections is questionable. For

example, records show that as of September 1997, the Boeing safety office was aware that

polyethylene foams and plastic bubble wraps had failed required flammability and ESD tests.

Despite those results, Boeing continued to use the materials. Photographs in Figure 1 and

Appendix D show their use in both facilities as of March 1998 and as recently as November

1999.

On November 3, 1999, Boeing safety officials, including the Senior Managers for Safety, and

Quality Assurance, stated that they were not aware of any (1) PFA's in either the SSPF or O&C

building or (2) variances allowing ground workers to use such materials. When we toured the

SSPF high bay a week later on November 10, 1999, we observed that all the various

polyethylene foams were in abundant use throughout the facility. The Kennedy Chief Safety

Officer stated that noncompliant PFA’s were used only as packaging material and did not pose a

hazard.

MUA’s Obtained for Some Materials

Although MUA’s were authorized for Boeing’s use of some of the materials, the MUA approval

process was not effective. On five occasions beginning on September 21, 1999, or after the start

of our audit, NASA used MUA’s to approve the use of some of the materials that failed required

tests. Four of the materials were polyethylene foam, and one was flash breaker tape used on ISS

hardware. The Kennedy CMR approved the MUA’s for the five materials based only on oral

assurance by Boeing materials and processes personnel that Boeing would use the materials

safely. The MUA approval process was not effective because (1) the CMR did not approve the

MUA’s in a timely manner, (2) Boeing did not support the MUA’s with documented risk
6

analyses, and (3) neither the Kennedy nor Boeing safety offices reviewed and approved the

MUA’s.

• Timely Completion. The Kennedy CMR approved the MUA’s 7 years after the materials

first failed required testing. Although test records show that some of the materials failed

required tests as early as July 1992, the Kennedy CMR and the Boeing materials and

processes representative did not sign the MUA’s until September and October 1999. KSCLO-8060.1 states that the CMR must have sufficient time for evaluation of the MUA prior to

the scheduled use of the material.

• Analyses. Boeing did not support the MUA’s with adequate analyses to identify and

mitigate potential risks. In addition, Boeing did not adequately monitor its use of potentially

hazardous materials and ensure that all affected parties clearly understood control

procedures. The PGOC requires that the Boeing PGOC Office of Safety prepare a risk

assessment of the safety impact for variances that are forwarded to NASA for approval.

• Safety Office Review. Neither the Kennedy nor Boeing safety offices reviewed the

MUA’s to ensure that Boeing personnel would use the materials in a manner that would not

put personnel or equipment at risk. The PGOC requires that all safety variances be reviewed

and approved by the NASA safety office. Boeing safety staff responsible for monitoring and

inspecting the SSPF and O&C building high bay areas told us that they were not aware of

any variances or waivers for the materials in use.

Risks of Using Potentially Hazardous Materials

By not ensuring that Boeing followed documented procedures and contract requirements for the

use of PFA’s, NASA lacks assurance that ground workers are using these materials in a safe and

controlled manner, especially with regard to their potential flammability and ESD.

• Flammability. For each of the flammability tests conducted, when personnel in the NASA

Materials Science Lab ignited the foam padding, the foam did not self-extinguish. In addition,

the foam padding dripped particles to lower surfaces, causing it to fail testing. Boeing

materials and processes personnel stated in the MUA’s that flammability risks were mitigated

by (1) covering the foam with film that passes required flammability tests or (2) using the foam

only on the floor of the SSPF. However, when we walked through the SSPF high bay areas,

we observed that the foam was abundantly used throughout the facility, including on vertical

surfaces. Furthermore, photographs of the SSPF and O&C building show that the foam was

used throughout both facilities, including on vertical surfaces. We did not observe foam

covered with film. Figure 1 shows ISS equipment in the O&C building, with the blue foam11

used in a non-horizontal position. If this material ignited and ground workers did not detect

 

11 An employee of the NASA Materials Science Lab identified the blue material in Figure 1 as L380FR

polyethylene foam.
7

the fire, there is a risk that it would not extinguish itself and would drip particles to lower

surfaces, causing more damage.
8

Figure 1. Blue Foam Used on the S Zero Truss Element of the ISS in O&C Building High Bay, November 9,

1999.

• ESD. When the NASA Materials Science Lab tested the foam padding, it held a static

electrical charge longer than the acceptable period. To pass testing, material can hold a

charge of only 350 volts for less than 5 seconds after termination of the initial charge. The

foam for which NASA issued MUA’s held a residual charge of more than 19,000 volts.

Boeing materials and processes personnel stated in the MUA’s that the contractor would

mitigate ESD risks by using the foam only where ESD was not a concern. However,

Boeing did not identify the location of those particular areas. When we toured the SSPF,

we observed that the foam padding was being used throughout the facility’s intermediate

and high bays, which significantly increased the risk of ESD. In addition, in January

1998, a mishap occurred in the SSPF in which a test technician incorrectly disconnected

an energized cable in the ISS Unity Node element.12 A NASA employee who was a

witness to the incident told us that the disconnect caused an electrical arc that was both

visible and audible. The witness further stated that the mishap could have been much

worse because the cable was surrounded by polyethylene foam that had failed the

required ESD tests.

The ultimate risk of improper use of these materials is damage or destruction of ISS hardware or

harm to ground workers. The Kennedy Director of Space Station and Shuttle Payloads

acknowledged this risk in a June 11, 1999, memorandum, which states:

 

12 The Unity Node is a connecting passageway to living and work areas of the ISS. It is the first major U.S.-

built component of the ISS and was launched into orbit in December 1998.

L380FR

Polyethylene

Foam
9

. . . With the introduction of ammonia, isopropyl alcohol, gaseous oxygen

and other hazardous materials into the O&C and SSPF, it is important that

materials and process (M&P) engineers control the use of plastic films,

foams, adhesive tapes (PFA’s) and solvents in these facilities. . . .

In that same memorandum, the Kennedy Director of Space Station and Shuttle Payloads directed

personnel to improve safety in the O&C building and the SSPF:

. . . all providers of hardware elements, support equipment, and payloads

shall remove and discard all noncomplying PFA’s within 24 hours of

arrival in a processing area . . . .

Customers currently on site and not using PFA’s that meet requirements .

. . will have 90 days upon receipt of this letter to remove noncompliant

PFA’s.

We did not observe any additional safety procedures implemented as a result of the

memorandum.

Contract Award Fees Received

Despite Boeing’s use of the potentially hazardous materials, it continually received the full award

fee for safety and mission assurance for each award fee evaluation period since January 1997.

The PGOC states that one of the purposes of the award fee provisions is to encourage and

reward the contractor for safe, timely, quality, cost-conscious performance in fulfilling the

requirements set forth in the contract. Item III. C.3 of the award fee evaluation criteria states:

Safety will be emphasized in all evaluations. Incidents attributable to the

contractor’s effort involving mission failure or degradation, employee

safety, equipment or hardware damage, or potential hazards will result in

significant loss of fee earning opportunity.

We reviewed the PGOC award fee data for the five completed evaluation periods since the

contract was converted to a performance-based contract in January 1997. For each period,

Boeing’s award fee was not affected by potentially unsafe practices including:

• Boeing’s continued use of polyethylene foam and plastic bubble wrap despite the Boeing

safety office’s knowledge that these materials failed required tests for flammability and ESD.

• The January 1998 close call in the SSPF when an energized cable in the ISS Unity Node that

was surrounded by the polyethylene foam was mistakenly disconnected.

• Input from an award fee performance monitor that stated that Boeing used incorrect methods

to obtain approval of unknown material, failed to follow proper procedures on material
10

approval, and failed to remove materials from the premises that had not passed required

testing.

**Deliberative process information omitted.**

Recommendations, Management’s Response, and Evaluation of

Response

Kennedy management provided extensive comments on our finding that are addressed in

Appendix F of this report.

The Director, John F. Kennedy Space Center, should:

1. Implement procedures to ensure the safe use of all materials (materials currently

in use and new materials introduced into the SSPF or O&C building) that do not meet

NASA and Kennedy requirements for flammability and ESD.

Management’s Response. Concur. Kennedy has undertaken additional measures to ensure

the safe use of materials that do not meet requirements for flammability and ESD. The complete

text of management's response is in Appendix E.

Evaluation of Management’s Response. Management's planned actions are responsive to

the recommendation. The recommendation is resolved, but will remain undispositioned and open

for reporting purposes until corrective actions are completed.

2. Clarify instructions for preparation of MUA’s to ensure that each MUA is

prepared in a timely manner, supported by a documented analysis, and reviewed and

approved by both contractor and Kennedy safety offices.

Management’s Response. Concur. The Kennedy Logistics Operations Directorate’s

Materials Science Laboratory, in conjunction with other Kennedy organizations, is rewriting the

procedure for the Center Materials and Processes Control Program, which covers the

preparation of MUA’s (see Appendix E).

Evaluation of Management’s Response. The actions planned by management are responsive

to the recommendation. The recommendation is resolved, but will remain undispositioned and

open for reporting purposes until corrective actions are completed.
11

3. Increase surveillance of Boeing’s inspection procedures. The surveillance should

ensure that Boeing (a) regularly inspects all potentially hazardous materials

including PFA’s; (b) ensures that all materials used are approved; (c) determines

whether an MUA was authorized, or is planned to be authorized for the use of the

materials not approved; and (d) promptly removes all materials that have not been

approved or for which an MUA has not been authorized.

Management’s Response. Concur. Among other noted implemented and planned corrective

actions, (1) the Kennedy Space Station and Payload Assurance organization has implemented an

increased awareness program for PFA’s (2) the NASA Safety Assurance Division will assure

that the contractor uses PFA’s in a safe, documented, and controlled manner, and (3) the NASA

Quality Assurance Division will conduct special audits on the contractor, and all nonconformance

noted will require contractor corrective and preventative action plans (see Appendix E).

Evaluation of Management’s Response. The actions planned by management are responsive

to the recommendation. The recommendation is resolved, but will remain undispositioned and

open for reporting purposes until corrective actions are completed.

4. Direct the PGOC Contracting Officer to determine whether there is a basis to

withhold all contract costs relating to noncompliant PFA’s

Management’s Response. Concur. The PGOC took prompt action to put appropriate

processes in place to assure proper control of PFA's. The PFA’s in question are materials that

have multiple valid uses on the contract, including in the SSPF and O&C building facilities when

used according to required procedures. Therefore, the costs of these materials meet the

"reasonableness" and "allocability" tests prescribed in Federal Acquisition Regulation section

31.201-2 in determining whether they are allowable. There is not a basis to consider

disallowance of costs (see Appendix E).

Evaluation of Management’s Response. The actions taken by management are responsive to

the recommendation. We consider the actions sufficient to disposition the recommendation,

which will be closed for reporting purposes.

5. Direct the PGOC Contracting Officer to ensure that proper surveillance of

contractor activities with regard to the proper use and control of PFA’s is conducted

and appropriate contract award fee action is taken if necessary.

Management’s Response. Concur. Kennedy has taken aggressive action to assure the

proper use of PFA’s. The contractor has, at this time, demonstrated that it has the proper

policies and procedures in place to ensure the safe and proper use and control of PFA’s.

Monitoring of this area of performance is being conducted to ensure that compliance with the

requirements continues (see Appendix E).
12

Evaluation of Management’s Response. The actions planned by management are responsive

to the recommendation. The recommendation is resolved, but will remain undispositioned and

open for reporting purposes until corrective actions are completed.
13

Appendix A. Objectives, Scope, and Methodology

Objectives

Our objectives, as discussed in this report, focused on safety concerns with Kennedy’s PGOC

that the Chairman of the U.S. House of Representatives’ Committee on Science brought to the

attention of the OIG in a February 25, 1999, letter. We reviewed the contractor’s operations to

determine whether:

• safety responsibilities between Boeing and NASA had been clearly defined,

• hazardous materials were being used in Kennedy’s processing facilities, and

• hazardous materials, if used, were properly controlled.

The overall objective of the audit, which will be addressed in a separate report, is to evaluate the

safety procedures of Agency contractors.

Scope and Methodology

To determine whether the PGOC clearly defined safety responsibilities for Boeing and NASA,

we:

• Reviewed the official PGOC file.

• Discussed the contract safety requirements with the NASA Contracting Officer, the

Contracting Officer’s Technical Representative, the Director of the Kennedy Space Station

and Shuttle Payloads Office, and staff in the Kennedy and Boeing safety offices.

To determine whether prohibited materials were used in Kennedy processing facilities and if so,

whether they were properly controlled, we:

• Reviewed the NASA and Kennedy requirements for materials testing, control, and approval

procedures.

• Reviewed Kennedy materials testing records dated from July 1992 through September 1999.

• Reviewed the applicable MUA’s.

• Discussed materials testing, control, and approval procedures with the Kennedy CMR,

NASA Materials Science Lab personnel, Boeing materials and processes officials, and safety

staff.
14

Appendix A

• Toured the SSPF and O&C building high bays.

Management Controls Reviewed

We reviewed management controls relative to safety requirements for NASA contracts as

described in NASA Handbook 1700.1, “NASA Safety Policy and Requirements Document.”

Specifically, we reviewed the Contracting Officer’s procedures for ensuring that specific

contractor safety tasks are clearly defined in the basic contract. The controls in place were

considered adequate. We also reviewed Kennedy’s procedures for approving the use of

materials that fail required testing procedures. As discussed in the finding, controls need to be

strengthened to ensure that the Kennedy and Boeing safety offices review and approve all

MUA’s and to ensure that a documented analysis is performed for each MUA.

Audit Field Work

We performed field work from October 1999 through January 2000 at NASA Headquarters and

Kennedy. We performed the audit in accordance with generally accepted government auditing

standards.
15

Appendix B. Materials Testing, Approval, and Control Requirements

The following policies are applicable to NASA’s requirements for testing, using, and controlling

hazardous materials:

NASA Handbook 1700.1, “NASA Safety Policy and Requirements Document,” June

1, 1993. The handbook is the central Agency document containing policy, safety requirements,

and guidelines that define the NASA safety program. The handbook states that the safety

organization with authority to establish a safety requirement is responsible for:

• reviewing and ruling on variances to the requirement, or

• delegating the responsibility for ruling on variances with possible

conditions placed on the approval process (e.g., requiring proper

analysis, risk assessment, and safety factor limits).

Kennedy Handbook 1710.2, “Kennedy Space Center Safety Practices Handbook,”

Revision D, November 1, 1998. The purpose of the handbook is to establish consolidated

safety requirements to define the parameters and boundaries required during design, operations,

and maintenance activities at Kennedy. The Kennedy office responsible for the handbook is the

Safety and Mission Assurance Directorate. The handbook states that when a requirement of the

handbook cannot be met, the requesting organization shall provide variance data information to

the Director of Safety and Mission Assurance.

Kennedy Handbook 1700.7, “Space Shuttle Payload Ground Safety Handbook,”

Revision C, August 19, 1999. The handbook aligns existing Department of Defense and

NASA ground safety criteria and establishes requirements for ground processing of

Shuttle payloads and associated ground support equipment. The Kennedy office responsible for

the handbook is the Safety and Mission Assurance Directorate. The handbook requires all

Kennedy payload organizations to comply with the established requirements or obtain a waiver

for each case in which compliance is infeasible. For operations at Kennedy, requesting

organizations should submit a waiver request to the Kennedy Director of Safety and Mission

Assurance. Information provided on the request should include, among other things, reasons for

noncompliance to the stated requirement and rationale for acceptance of the waiver, including any

required support data and drawings, and a list of possible methods and techniques used in

mitigating the hazards. Also, the handbook states that payload organizations shall select from the

approved materials lists, those materials susceptible to the generation, collection, and holding of

static electrical charges. The handbook further states that use of flammable materials and staticproducing materials shall be kept to a minimum in all payload-processing areas.
16

Appendix B

KSC [Kennedy Space Center]-LO-8060.1, “KSC [Kennedy Space Center] Materials

and Processes Control Program,” July 15, 1997. The document establishes the policy and

steps to be followed by all organizational elements at Kennedy in the selection of materials.

Organizations at Kennedy are required to submit to the Kennedy CMR analysis and test results

to show that selected materials meet safety requirements. If NASA or contractor personnel

choose materials that do not meet such requirements, the organization must submit an MUA to

the CMR. The CMR must have sufficient time for evaluation of the MUA prior to the scheduled

use of the material.

KDP [Kennedy Document Procedure]-P-2207, “Safety Variance Process,”

Revision A, November 1998. The objective of this guidance is to provide an efficient and

accurate method of documenting and tracking variances pertaining to established safety policies.

The variance process assures (1) appropriate organizations are accountable, (2) operations are

safe, (3) risks are acceptable, (4) contract requirements are met, and (5) Federal and agency

requirements are met. Administrators from the Safety and Mission Assurance Directorate must

review and evaluate variance requests to ensure that the risks and rationale associated with the

variance are acceptable. The document states that the Kennedy Director of Safety and Mission

Assurance shall approve all variances.

Payload Ground Operations Contract (PGOC), NAS10-11400. In accordance with

Appendix 11 of contract NAS10-11400, Boeing shall “establish a means to analyze the safety

impact” for proposed waivers and deviations.

NASA Technical Standard 6001, “Flammability, Odor, Offgassing, and Compatibility

Requirements and Test Procedures for Materials in Environments That Support

Combustion,” February 9, 1998. This document establishes the technical requirements for

evaluation, testing, and selection of materials to preclude unsafe conditions related to flammability

and other hazards. This document does not address variance policies and procedures for using

materials that fail the required test.
17

Appendix C. Hazardous Materials Test Results

Material Test Dates & Results MUA Date & Rationale

for Use

Audit Observations

Red, white, or blue L380FR-B

Polyethylene Foam.

Manufactured by United

Foam Plastics Corporation.

NASA first tested these materials

on 7/31/92. Test results were:

Flammability: Failed. Samples of

each material dripped flaming

particles, igniting test paper below

the test materials.

ESD: Failed. Samples of each

material maintained a residual

charge of more than 19,000 volts of

electricity 5 seconds after

termination of a static charge. The

minimum charge allowable was 350

volts.

The Kennedy CMR

signed the MUA on

9/20/99, and the Boeing

materials and processes

representative signed on

9/21/99. Boeing will use

the foam as a pallet

protective pad and must

cover or move material if

ESD is a concern.

There was no MUA for

the green foam. Figures

2 and 4 in Appendix D

show these foams on

ISS hardware

throughout the SSPF.

Blue L380FR-B Polyethylene

Foam. Manufactured by

United Foam Plastics

Corporation

The Kennedy CMR

signed an MUA on

9/20/99, and the Boeing

materials and processes

representative signed on

9/21/99. Boeing will use

the foam for ISS

equipment.

None

Red, white, or blue L380FR-B

Polyethylene Foam.

Manufactured by United

Foam Plastics Corporation

The Kennedy CMR and

Boeing materials and

processes representative

signed an MUA on

10/7/99. Boeing will use

material in only horizontal

position, on the floor

where ESD is not a

concern.

The MUA did not

include the green foam.

Photographs of the

O&C building (Figure 1

page 7) and the SSPF

(Figures 2 and 4,

Appendix D) show the

foam in positions other

than on the floor.

Miscellaneous foam

padding, including L380FRB Polyethylene Foam.

The Kennedy CMR and

Boeing materials and

processes representative

signed an MUA on

10/7/99. The material

failed all tests, but Boeing

will cover material with an

approved plastic film. If

the plastic film tears,

Boeing should remove

materials immediately.

During our walkthroughs of the O&C

building and SSPF, we

observed that foam was

not covered with

plastic.
18

Appendix C

Material Test Dates & Results MUA Date & Rationale

for Use

Audit Observations

Flashbreaker 2 Tape.

Manufactured by

Airtech International, Inc.

NASA tested this material in April

1999. Preliminary test results were:

Flammability: Failed. A test

sample did not self-extinguish

within the allowable parameters.

ESD: Failed. A sample of the

material maintained a residual

charge of more than 19,000 volts of

electricity 5 seconds after

termination of a static charge. The

minimum charge allowable was 350

volts.

The Kennedy CMR

signed an MUA on

9/20/99, and the Boeing

materials and processes

representative signed on

9/21/99. Boeing will use

material on ISS hardware

because it does not

contaminate hardware

surfaces. NASA could

not find a tape that passed

contamination,

flammability, and ESD

tests.

None

Clear Bubble Wrap.

Manufacturer unknown.

NASA tested this material on

12/19/97. Preliminary test results

were:

Flammability: Failed. A sample of

the material dripped flaming

particles, igniting test paper below

the test material.

The Kennedy CMR and

Boeing materials and

processes representative

have not signed MUA’s

for these materials.

NASA and Boeing

personnel told us that

they do not permit

bubble wrap in any of

the processing facilities.

Although vendors may

use it as packing

material, Boeing

personnel are to

immediately discard the

material upon receipt of

payloads from vendors.

However, Figure 3,

Appendix D, shows use

of clear and pink bubble

wrap.

SC120 Pink Bubble Wrap.

Manufactured by Sealed Air

Corporation.

NASA tested this material on

12/23/97. Test results were:

Flammability: Failed. A sample of

the material dripped flaming

particles, igniting test paper below

the test material.

ESD: Failed. A sample of the

material maintained a residual

charge of more than 4,000 volts of

electricity 5 seconds after

termination of a static charge. The

minimum charge allowable was 350

volts.
19
20

Appendix D. Polyethylene Foam and Bubble Wrap Usage

 Figure 2. Blue Foam* on ISS Unity Module in SSPF High Bay, March 9, 1998.

 

Figure 3. Pink and Clear Plastic Bubble Wrap* on the ISS Pressurized Mating Adapter 2 in SSPF

High Bay, April 28, 1998.

*An employee of the NASA Materials Science Lab identified the blue material in Figure 2 as L380FR-B

polyethylene foam and the plastic materials in Figure 3 as clear and pink bubble wrap.

L380FR-B

Polyethylene

Foam

Clear Bubble

Wrap

Pink Bubble

Wrap
21

Appendix D

Figure 4. Red and Green Foams* on the ISS Unity Module in SSPF High Bay, August 27, 1998.

* An employee of the NASA Materials Science Lab identified the red and green material in Figure 4 as

L380FR-B polyethylene foam.

L380FR-B

Polyethylen

e Foam
19

Appendix E. Management’s Response

See Appendix F,

OIG Comment 1

See Appendix F,

OIG Comment 2
20

Appendix E
21

Appendix E
22

Appendix E
23

Appendix E
24

Appendix E
25

Appendix E
26

Appendix E

e Appendix F,

G Comment 3

e Appendix F,

G Comment 4

e Appendix F,

G Comment 5

e Appendix F,

G Comment 6
27

Appendix E

See Appendix F,

OIG Comment 7

See Appendix F,

OIG Comment 8

See Appendix F,

OIG Comment 5

See Appendix F,

OIG Comment 9

See Appendix F,

OIG Comment 10

See Appendix F,

OIG Comment 5
28

Appendix E

e Appendix F,

G Comment 5

e Appendix F,

G Comment 11

e Appendix F,

G Comment 12

e Appendix F,

G Comment 13

e Appendix F,

G Comment 14
29
30

Appendix F. OIG Comments on Management’s Response

Kennedy management provided the following general and specific comments in response to our

draft report. Our responses to the comments are also presented.

Management’s Comment. The report focuses on one issue of questionable importance.

1. OIG Comments. The scope of the audit focused on specific safety concerns provided to the

OIG by the Chairman of the House of Representatives Committee on Science. One of these

concerns was the use of potentially hazardous materials in the SSPF and O&C building.

Implementation of our recommendations will help ensure the safe usage of PFA's in these facilities

and possibly prevent the occurrence of incidents regarding their use.

Management’s Comment. Foremost among our concerns is that the general public and press

will reach the conclusion that Kennedy and its payload ground processing contractor routinely

tolerated the existence of potentially hazardous materials in its payload processing facilities and

that the level of risk is high.

2. OIG Comments. Based on our audit work, which was performed in accordance with

generally accepted government auditing standards and included first-hand observations and a

detailed review of materials testing records, we concluded that Kennedy and its payload ground

processing contractor routinely tolerated the existence of potentially hazardous materials in its

payload processing facilities. Kennedy management provided no documentation or risk analyses

to support the level of risk associated with the materials. Therefore, we could not attest to the

level of risk associated with using the materials.

Management’s Comment. NASA-STD-6001, “Flammability, Odor, Offgassing, and

Compatibility Requirements and Test Procedures for Materials in Environments that Support

Combustion,” dated February 9, 1998, is approved for use by NASA Headquarters and all Field

Centers to establish requirements for evaluation, testing, and selection of materials. Several

statements in the audit report are in conflict with the requirements of the NASA standard, as

detailed under our "Specific Comments."

3. OIG Comments. NASA-STD-6001, “Flammability, Odor, Offgassing, and Compatibility

Requirements and Test Procedures for Materials in Environments That Support Combustion,”

February 9, 1998 is a technical document that specifies the actual testing procedures for

materials. It does not address specific safety procedures to follow when using materials that fail

required tests, the primary issue in the audit report. Paragraph 1 of the standard states:
31

Appendix F

Systems containing materials that have not been tested or do not meet the

criteria of the required tests must be verified to be acceptable in the use

configuration by analysis or testing. This verification rationale must be

documented and submitted to the responsible NASA center materials

organization for approval.

Our concern, as described in the report, is the weakness in Kennedy’s process for verifying the

acceptability of materials that failed the required tests. Furthermore, as stated in the introduction

section of NASA-STD-6001, it is not intended to be the sole guidance for controlling materials.

NASA-STD-6001 is one of many documents that comprise Kennedy’s material control program

and its requirements. Management stated in its response to recommendation 1 that it is notifying

all payload processing contractors, users, and customers that McDonnell Douglas Procedure,

MDP-0808, “Control Plans for Non-flight Materials and Equipment Approved for Use in and

Around Shuttle Payloads During STS Payload Operations,” is the governing document controlling

the use of PFA’s. Both the current version of MDP-0808, dated March 6, 2000, and the

PGOC reference NASA, Kennedy, and Boeing safety requirements, which should apply to the

conditions identified during the audit and detailed in the report.

Management’s Comment. Noncompliant plastics never posed a hazard to personnel in either

the SSPF or the O&C building since no operations or chemicals are involved that could

conceivably react with any noncompliant plastics.

4. OIG Comments. Management’s position that noncompliant plastics never posed a hazard to

personnel has never been documented, supported by an adequate analysis, or reviewed and

approved by safety personnel as required by the PGOC contract, NASA, or Kennedy safety

requirements. Thus, we cannot attest to the level of risk associated with using this material other

than to conclude that the material is potentially hazardous.

Management’s Comment. The term “hazardous materials” is misused throughout the report.

PFA's are not classified by any regulatory agency as hazardous materials. These materials can

contribute to a hazardous situation, if not properly controlled, but the PFA's used in the Space

Program are no different than materials found in any average workplace or household.

5. OIG Comments. We use the term “potentially hazardous materials” throughout the report.

In contrast to this comment, management also states on the first page of its response that "PFA's

have the potential to create a hazardous condition if not properly handled or controlled." As we

found during the audit and as documented throughout the
32

Appendix F

report, Kennedy did not properly control these materials as evidenced by the lack of documented

risk analyses and safety office review and approval. The abundant improper uses of the

materials, as was observed during our walk-through and as evidenced in the report photographs,

indicate the lack of control over these materials and the potential hazards that exist.

If management's position is that these materials do not pose a potential hazard, we question why

Kennedy would subject the materials to expensive and elaborate testing requirements. Finally,

household materials are generally not subject to the same detailed U.S. Government testing

requirements as were the PFA’s used in Kennedy’s facilities.

Management’s Comment. The term “variance” is a safety term and not one that applies to the

materials control process. The NASA/contractor safety offices are not required to review the

MUA’s. NASA-STD-6001 does not require safety organizations to approve materials.

6. OIG Comments. Management stated that the materials in question could contribute to a

hazardous situation if not properly handled or controlled. Further, some of Kennedy

management’s own actions indicate that the proper use and control of materials was indeed a

matter of safety. For example, management:

• Formed a working group, with both Kennedy and Boeing safety office representatives, to

address the control of PFA's.

• Placed a large placard in the lobby of the SSPF warning employees to use caution with

PFA's.

• Issued a memorandum that stated, with the introduction of ammonia, isopropyl alcohol,

gaseous oxygen, and other hazardous materials into the SSPF and O&C building, it was

important to control the use of PFA's to ensure safety, contamination control, and mission

success.

Further proof that safety applies to the materials control process is on the Materials Science

Division's Intranet. The Intranet, referenced by the placard in the lobby of the SSPF, states that

“the use of processing materials in hazardous and contamination controlled areas must be

approved by the KSC Safety Office.” Furthermore, the current version of MDP-0808, dated

March 6, 2000, states, “Approval of an MUA is the responsibility of Boeing Materials and

Process Engineering and [emphasis added] Boeing Safety Health and Environmental Affairs.”
33

Appendix F

For these reasons, we believe that the proper control of PFA's is a safety matter requiring the

preparation of a safety variance for any material that does not meet required testing criteria.

According to KHB 1710.2, Kennedy Space Center Safety Practices Handbook, “Adhesive

tapes and plastic films used in Kennedy flight hardware processing facilities shall only be used for

operations where they meet the acceptance criteria for their specified use.” As stated in

Appendix B of this report, a deviation from a requirement of the handbook requires a safety

variance from the Director of the Kennedy safety organization. An MUA would fit the criteria for

a safety variance if it is supported by an adequate documented analysis and a safety office review

and approval and if it is prepared before the material in question is used. As stated in the report,

the MUA’s that Kennedy used were not prepared in a timely manner, were not supported by an

adequate analysis, and were not reviewed by the Kennedy safety office.

Management Comment. NASA did identify the concern about nonapproved PFA's in the

Kennedy Director of Space Station and Shuttle Payloads letter, dated June 11, 1999, which is

referenced in the report on pages 7-8.

7. OIG Comments. The June 11, 1999, letter from the Kennedy Director of Space Station and

Shuttle Payloads identified only a concern about using nonapproved PFA's. The letter did not

identify and appropriately mitigate the risks of using those materials. Kennedy had been using

nonapproved plastics and foams for at least 7 years prior to the letter being signed. Further, we

observed no additional safety procedures implemented as a result of the letter.

Management Comment. The Background paragraph contains a sentence that is incorrect. The

NASA Center Materials Representative, not Safety, is responsible for the testing and evaluation

of materials against a set of requirements.

8. OIG Comments. As stated in the second sentence of the same paragraph, we recognize that

the NASA Materials Sciences Lab is responsible for testing all materials against flammability and

ESD requirements. The word “safety” has been removed from the first sentence.

Management Comment. Add the word “potentially” before “hazardous to ground workers.”

9. OIG Comments. The sentence has been revised to include the word “potentially.”

Management Comment. In Footnote 5, it is not the material being used that is sensitive to a

static electric build up.

10. OIG Comments. The footnote has been revised.

Appendix F
34

Management Comment. What is a timely manner? Some MUA’s require little or no

modifications. However, under certain conditions, MUA’s may require as many as 3 to 6 months

to perform a complete analysis and any testing that may be required.

11. OIG Comments. In our opinion, a timely manner would be to finalize the MUA before the

material that has failed testing is used. An elapsed time of 7 years after the material is first tested

is not timely.

Management’s Comment. Boeing was not building ISS components at Kennedy in 1992;

therefore, no MUA’s were prepared until after the ISS program decided to move construction to

Kennedy.

12. OIG Comments. PGOC personnel (McDonnell Douglas or Boeing) have been performing

payload processing activities at various Kennedy facilities since the PGOC was awarded in 1987.

Such activities have not been limited to the ISS program and have included other Space Shuttle

and expendable launch vehicle payloads.

Management Comment. The materials referred to as being in abundance in the November

walkdown of the high bay were already approved for use by MUA’s dated September 1999.

13. OIG Comments. Although the CMR and Boeing materials and process representative may

have signed the MUA’s in September 1999, we observed that the foam was not properly

controlled or used in accordance with the MUA’s. The photographs in the report support our

observations. For example, the MUA’s required that the foam be used only on the floor of the

SSPF or be covered with a film that passed required tests. We did not observe any foam

covered with this film. We observed foam abundantly used on vertical surfaces, an unapproved

use, as well as the floor of the SSPF, as permitted by the MUA. We also observed the use of

green foam in the SSPF that did not have an approved MUA. As described in the report and

acknowledged in management’s response, PFA's have the potential to create a hazardous

condition if not properly controlled.

Management Comment. There is no requirement for the safety offices to approve MUA’s.

14. OIG Comments. As noted in OIG Comment 6, the current version of MDP-0808, dated

March 6, 2000, specifically states that approval of MUA’s is the responsibility of the Boeing

materials and process engineering and safety offices. According to management’s response to

Recommendation 1, all processing personnel will be informed that MDP-0808 is the governing

document controlling the usage of PFA's in Kennedy processing areas. As such, there clearly is a

requirement for safety office approval.
35

Appendix F

Management Comment. The S Zero Truss, in the photograph on page 7 of the report, is in an

area specifically designated as a commercial processing area that belongs to the Boeing prime

contract, and anything that occurs in that area has no relationship or bearing on the PGOC. The

photograph is dated November 9, 1999 and the MUA approving the material was signed in

September 1999.

15. OIG Comments. The purpose of the photograph was to show that foam padding was

being used in a vertical position, which was contrary to the September 1999 MUA, which

requires that the foam padding be used only on the floor of the building. Conversion of the

PGOC to a performance-based contract clearly established Boeing’s overall safety

responsibilities for various Kennedy processing facilities, including the O&C building.

Management Comment. The January 1998 close call in the SSPF was a Boeing Prime close

call and not a PGOC close call and, therefore, was not written as an award fee issue on the

PGOC

16. OIG Comments. Regardless of who incurred the close call, a hazard was made potentially

worse by the existence of the noncompliant foam. Despite this incident and Boeing's overall

responsibility for safety, the situation was not even considered as part of the award fee evaluation

process. As stated in the report, Boeing has industrial safety responsibilities for the SSPF, which

includes mishap reporting. This close call was not recorded in Kennedy’s Incident Reporting

Information System for proper tracking and disposition, indicating a potentially serious flaw in

Kennedy’s safety program.

**Deliberative process information omitted.**
36

Appendix G. Report Distribution

National Aeronautics and Space Administration (NASA) Headquarters

A/Administrator

AI/Associate Deputy Administrator

B/Chief Financial Officer

B/Comptroller

BF/Director, Financial Management Division

C/Associate Administrator for Headquarters Operations

G/General Counsel

H/Associate Administrator for Procurement

J/Associate Administrator for Management Systems

JM/Director, Management Assessment Division

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

QS/Director, Safety and Risk Management Division

R/Associate Administrator for Aero-Space Technology

S/Associate Administrator for Space Science

U/Associate Administrator for Life and Microgravity Sciences and Applications

Y/Associate Administrator for Earth Science

Z/Associate Administrator for Policy and Plans

NASA Centers

Director, John F. Kennedy Space Center

 Chief Counsel, John F. Kennedy Space Center

Non-NASA Federal Organizations and Individuals

Assistant to the President for Science and Technology Policy

Deputy Associate Director, Energy and Science Division, Office of Management

 and Budget

Branch Chief, Science and Space Programs Branch, Energy and Science Division,
37

 Office of Management and Budget
38

Appendix G

Non-NASA Federal Organizations and Individuals (Cont.)

Associate Director, National Security and International Affairs Division, Defense

 Acquisitions Issues, General Accounting Office

Professional Assistant, Senate Subcommittee on Science, Technology, and Space

Chairman and Ranking Minority Member – Congressional Committees and

Subcommittees

Senate Committee on Appropriations

Senate Subcommittee on VA, HUD, and 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, and Independent Agencies

House Committee on Government Reform

House Subcommittee on Government Management, Information, and Technology

House Subcommittee on National Security, Veterans Affairs, and

 International Relations

House Committee on Science

House Subcommittee on Space and Aeronautics

Congressional Members

Honorable Pete Sessions, U.S. House of Representatives

Honorable F. James Sensenbrenner, Jr., U.S. House of Representatives
NASA Assistant Inspector General for Auditing

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