SEPTEMBER 3, 2008 

REVIEW REPORT

REPORT NO. IG-08-027 (ASSIGNMENT NO. S-06-011-01) 

OFFICE OF AUDITS

GLENN RESEARCH CENTER NEEDS TO BETTER DEFINE 

ROLES AND RESPONSIBILITIES FOR 

EMERGENCY RESPONSE

OFFICE OF INSPECTOR GENERAL

National Aeronautics and 

Space Administration 

 
Final report released by: 

 signed 

Evelyn R. Klemstine 

Assistant Inspector General for Auditing 

Acronyms 

EPP Emergency Preparedness Plan 

ERT Emergency Response Team 

FY Fiscal Year 

HSPD Homeland Security Presidential Directive 

ICS Incident Command System 

IRIS Incident Reporting Information System 

MOU Memorandum of Understanding 

NIMS National Incident Management System 

NPR NASA Procedural Requirements 

SCBA Self-Contained Breathing Apparatus 

REPORT NO. IG-08-027 
SEPTEMBER 3, 2008 

REPORT NO. IG-08-027 

OVERVIEW

GLENN RESEARCH CENTER NEEDS TO BETTER DEFINE ROLES 

AND RESPONSIBILITIES FOR EMERGENCY RESPONSE

The Issue 

This review was initiated in response to two hotline complaints concerning the Glenn 

Research Center at Lewis Field: the first concerned laboratory safety and the review 

process for granting safety permits, and the second concerned first responders and their 

actions during a January 2006 fire in a Glenn underground tunnel. Our report, “Effective 

Inspection Program Key to Improving Laboratory Safety at Glenn Research Center” 

(IG-07-032, September 24, 2007), addressed laboratory safety and the process for 

reviewing, approving, and maintaining safety permits for Glenn laboratory operations. 

This report addresses the response to Glenn emergencies. 

The primary goal of an emergency response system is to mitigate the harmful effects of 

an emergency by preventing loss of life, serious injury, and damage to property or the 

environment. Federal requirements for emergency response are contained in Homeland 

Security Presidential Directive (HSPD)-5, “Management of Domestic Incidents,” 

February 28, 2003. HSPD-5 establishes general emergency response requirements for all 

Federal agencies and requires that Federal agencies develop and administer the National 

Incident Management System (NIMS). NIMS provides a consistent Nation-wide 

template to enable all government, private sector, and nongovernmental organizations to 

work together during domestic incidents and includes the implementation of an Incident 

Command System (ICS) during each emergency response. ICS is a standard, on-scene, 

all-hazards incident management system that applies to firefighters, law enforcement 

personnel, hazardous materials teams, rescuers, and emergency medical teams. ICS is 

designed to facilitate the work of cross-functional teams in a smooth, coordinated effort 

under a single management system. This enables responders to effectively work together 

in preparing for, preventing, responding to, and recovering from emergencies. 

At Glenn, the organizations responsible for emergency response include the Office of 

Security Management and Safeguards; the Safety and Mission Assurance Directorate; 

and the municipalities of Brook Park, Ohio, and Fairview Park, Ohio. The Glenn 

Emergency Management Coordinator is assigned to the Office of Security Management 

and Safeguards and is responsible for preparing the Glenn Emergency Preparedness Plan 

(EPP). The Glenn EPP requires that emergency responders comply with ICS during all 

Center emergencies. 
OVERVIEW

ii REPORT NO. IG-08-027 

We reviewed the management of Glenn’s emergency response system and its adherence 

to Federal and NASA guidance. We analyzed the actions taken by Glenn responders 

during 10 of the 572 emergencies experienced at Glenn during fiscal years (FYs) 2005 

through 2007. The details of our review’s scope and methodology are in Appendix A. 

Results 

The lack of clearly defined roles, responsibilities, and lines of authority for Glenn 

responders, along with the absence of memorandums of understanding (MOU) with offsite responding organizations, has negatively affected the Center’s ability to implement 

ICS and respond effectively to emergencies. When ICS is not properly implemented 

during an emergency, the chain of command and lines of communication can become 

confused, increasing the risk of injury for responders and other personnel, as well as 

increasing the risk of damage to NASA assets. For at least two of the emergencies that 

we reviewed, that confusion could have resulted in serious injury to the responders and 

further damage to Glenn assets. 

We found that the Glenn first responders failed to adequately implement ICS during each 

of the 10 emergencies that we reviewed. Specifically, Glenn emergency responders 

• did not keep a safe distance from the emergency scene or adequately assess the 

nature of the emergency (2 out of 10); 

• did not initiate an emergency notification protocol based on the severity and type 

of emergency (5 out of 10); 

• failed to isolate and deny entry into areas “immediately dangerous to life and 

health”1 (3 out of 10); 

• allowed personnel to enter hazardous environments without appropriate 

respiratory protection (2 out of 10); 

• failed to provide critical institutional information to responding fire departments 

(4 out of 10); and 

• failed to ensure that all reports related to the emergency response contained 

accurate and consistent information (10 out of 10). 

Although the EPP required Glenn emergency responders to implement ICS when 

responding to emergencies, it did not clearly define the roles, responsibilities, authority, 

and limitations for each of the responders and responding organizations under ICS. In 

 

1

 An area with an atmosphere that will cause irreversible adverse health effects or impair an individual’s 

ability to escape is “immediately dangerous to life and health,” according to the Occupational Safety and 

Health Administration Act, 29 Code of Federal Regulations 1910 (Standard Number 1910.134). 
OVERVIEW

REPORT NO. IG-08-027 iii 

addition, Glenn did not have MOUs with local police, fire, and rescue departments 

designating how they should coordinate and integrate with the Glenn responders during 

an emergency. Glenn’s ability to respond effectively to on-site emergencies is contingent 

on the mobilization and use of resources from multiple and diverse response 

organizations. When properly implemented, ICS provides a management system that 

allows these resources to be effectively managed and integrated. 

Management Action 

To improve the effectiveness of Glenn’s emergency response system, we recommended 

that the Chief, Office of Security Management and Safeguards, review the roles and 

responsibilities assigned to each of the responding organizations and ensure that the 

responders are qualified to assume those roles and responsibilities and can effectively and 

timely respond to Glenn emergencies. Once the review is completed, the Chief, Office of 

Security Management and Safeguards, should revise the EPP, if necessary, based on the 

results of the review. We also recommended that the Chief, Office of Security 

Management and Safeguards, revise the EPP to require that each Glenn organization with 

an emergency response role develop standard operating procedures detailing the specific 

responsibilities for their respective responder personnel. To ensure that the standard 

operating procedures complement the EPP and do not provide contradictory information, 

we recommended that the EPP be revised to require the Glenn Emergency Management 

Coordinator to review and approve the standard operating procedures before 

implementation. We also recommended that the EPP require the Emergency 

Management Coordinator to reconcile all emergency response reports filed, to include 

those by off-site responding organizations, to ensure that the reports are accurate and 

consistent. Finally, we recommended that the Glenn Director establish MOUs with all 

non-NASA organizations that respond to emergencies at the Center. The Emergency 

Management Coordinator should participate in developing those MOUs. 

In a response to a draft of this report, the Glenn Director concurred with our 

recommendations and described actions to be taken by the Center to improve the 

effectiveness of Glenn’s emergency response system. First, the Glenn Emergency 

Management Coordinator will review the roles and responsibilities of on-site and off-site 

emergency responders by November 30, 2009. Second, the Chief, Office of Security 

Management and Safeguards, in conjunction with the Director of Center Operations, the 

Director of Safety and Mission Assurance, and the Emergency Management Coordinator 

will analyze and determine the best organization for emergency response and incorporate 

the results into the Center EPP by July 30, 2009. Third, the Emergency Management 

Coordinator, in cooperation with the Chief, Security Management and Safeguards Office; 

Chief, Safety, Health, and Environmental Division; the Office of Chief Counsel; and the 

Center Director’s Office, will initiate negotiations to establish MOUs with adjoining or 

jurisdictional organizations that provide fire suppression, fire rescue, emergency medical 

services, police, and hazardous chemicals and materials response by December 10, 2009. 

Fourth, the Safety, Health, and Environmental Division will develop a new emergency 
OVERVIEW

iv REPORT NO. IG-08-027 

action plan for each facility at Glenn by April 23, 2009. (See Appendix B for the full text 

of management’s comments.) 

Within the period of the audit, Glenn instituted the use of the ICS and implemented an 

aggressive training effort to upgrade the credentials of emergency responders. Glenn 

indicated in their response that they have met and exceeded all NASA required NIMS 

training by training 114 individuals, with seven of the 114 trained to ICS 300 level and 

five of the 114 trained to the ICS 400 level. 

We consider management’s proposed actions to be responsive. The recommendations 

are resolved and will be closed following verification that all actions have been 

completed. 
September 3, 2008 

REPORT NO. IG-08-027 

CONTENTS

INTRODUCTION

Background __________________________________________ 1 

Objectives ___________________________________________ 2 

Other Matters of Interest _______________________________ 2 

RESULTS

ICS Not Adequately Implemented during 

Glenn Emergencies __________________________________ 3 

APPENDIX A 

Scope and Methodology _______________________________ 17 

Review of Internal Controls _____________________________ 18 

Prior Coverage ______________________________________ 18 

APPENDIX B 

Management Comments _______________________________ 20 

APPENDIX C 

Report Distribution ___________________________________ 25 

September 3, 2008 

REPORT NO. IG-08-027 1 

INTRODUCTION

Background 

The primary goal of an emergency response system is to effectively mitigate or lessen the 

harmful effects from an emergency by preventing loss of life, serious injury, and damage 

to property or the environment. Common elements of an emergency response system are 

site assessment, safety, rescue, containment, mitigation, recovery, and documentation. 

The Federal Government established general emergency response requirements in 

Homeland Security Presidential Directive (HSPD)-5, “Management of Domestic 

Incidents,” February 28, 2003. HSPD-5 directs all Federal agencies to develop and 

administer a National Incident Management System (NIMS). NIMS provides a 

consistent approach that enables Federal, state, and local governments to work together in 

preparing for, preventing, responding to, and recovering from emergencies. NIMS 

requires the implementation of an Incident Command System (ICS), which is an on-scene 

management system that provides a standard structured approach for responding to 

emergencies. 

Incident Command System. ICS is a standard, on-scene, all-hazards incident 

management system that is used by all levels of government—Federal, state, and local—

as well as many private sector and nongovernmental organizations. ICS is applicable 

across all disciplines, including firefighters, law enforcement personnel, hazardous 

materials teams, rescuers, and emergency medical teams. The system is not exclusive to 

any single discipline or circumstance; instead, ICS is designed to be flexible, allowing 

responders from all jurisdictional levels and across all functional disciplines to work 

together in a smooth, coordinated effort under a single management system. ICS uses a 

top-down modular organizational structure that emphasizes a strict chain of command 

that begins with the on-scene Incident Commander. The Incident Commander is the 

individual in overall command of the emergency response effort. The first responder on 

the scene assumes the role of the Incident Commander until relieved by a more qualified 

authority, such as the fire chief in the case of a fire. 

Glenn Research Center Emergency Response Organizations. The primary 

organizations responsible for emergency response at Glenn are as follows: 

• The Office of Security Management and Safeguards, Center Operations 

Directorate, is responsible for Glenn’s Emergency Preparedness Program and 

emergency response for all security-related emergencies. Within the Office of 

Security Management and Safeguards are the Emergency Management 

Coordinator and the support services contactor, Knight Protective Services, which 

provides security guards and dispatchers. 
INTRODUCTION

2 REPORT NO. IG-08-027 

• The Safety, Health, and Environmental Division of Glenn’s Safety and Mission 

Assurance Directorate is responsible for emergency response for non-security 

related emergencies. Within the Division’s Safety Branch, selected safety 

specialists are designated as Center “first responders.” As part of their duties, 

those personnel are required to respond to all Glenn emergencies during regular 

duty hours. The Division also provides occupational health specialists and 

environmental engineers when needed for injuries or chemical spills. 

• The municipalities of Brook Park and Fairview Park provide fire, medical, and 

police services for Glenn emergencies such as fires, personnel injury, chemical 

spills, and criminal investigations. 

Depending on the type and severity of the emergency, Glenn may also deploy an Emergency 

Response Team (ERT). In addition to personnel from Glenn’s Security and Safety Offices, 

the ERT may include personnel with other functional areas of expertise (such as facilities, 

communications, and media relations). 

NASA Guidance. NASA’s implementing guidance for NIMS is contained in NASA 

Procedural Requirements (NPR) 8715.2, “NASA Emergency Preparedness Plan 

Procedural Requirements,” Change 3, March 3, 2005. In accordance with NPR 8715.2, 

Glenn developed and implemented an Emergency Preparedness Plan (EPP) in October 

2006. The Glenn EPP requires that emergency responders comply with ICS during all 

Center emergencies. 

Objectives 

Our overall objective was to evaluate the effectiveness of Glenn’s emergency response 

system. Specifically, we evaluated the adequacy of Glenn’s emergency response policies 

and procedures, the implementation of those policies and procedures, and Glenn 

management’s oversight of the emergency response system. See Appendix A for details 

of the review’s scope and methodology, our review of internal controls, and prior 

coverage. 

Other Matters of Interest 

During our review, we identified nine Glenn facilities that had inadequate emergency 

evacuation plans. Because evacuation plans are an element of emergency preparedness 

and not emergency response, we discuss the issue separately on page 13 of this report. 

The discussion describes the need for Glenn to ensure that evacuation plans are up to date 

and that the plans include maps showing both primary and secondary routes of escape. 
RESULTS

REPORT NO. IG-08-027 3 

ICS NOT ADEQUATELY 

IMPLEMENTED DURING 

GLENN EMERGENCIES

Glenn first responders failed to adequately implement ICS during each of the 

emergencies that we reviewed. Specifically, we identified 26 instances of ICS 

noncompliance during our review of 10 Glenn emergencies that occurred during 

fiscal year (FY) 2005 through FY 2007. For those 10 emergencies, the Glenn 

emergency responders 

• did not keep a safe distance from the emergency scene or adequately assess 

the nature of the emergency (2 out of 10); 

• did not initiate an emergency notification protocol based on the severity and 

type of emergency (5 out of 10); 

• failed to isolate and deny entry into areas “immediately dangerous to life and 

health”2

 (3 out of 10); 

• allowed personnel to enter hazardous environments without appropriate 

respiratory protection (2 out of 10); 

• failed to provide critical institutional information to responding fire 

departments (4 out of 10); and 

• failed to ensure that all reports related to the emergency response contained 

accurate and consistent information (10 out of 10). 

Noncompliance with ICS occurred due to the lack of clear guidance regarding the 

roles and responsibilities of the Glenn responders and the responding organizations. 

Although the EPP contained general information concerning those roles and 

responsibilities, it did not require that more specific guidance be prepared at the 

organizational level. In addition, Glenn did not have memorandums of 

understanding (MOUs) with local police, fire, and rescue departments designating 

how they should coordinate and integrate with the Glenn responders during an 

emergency. 

The lack of clearly defined roles, responsibilities, and lines of authority for Glenn 

responders, along with the absence of MOUs with off-site responding organizations, 

has negatively affected the Center’s ability to respond effectively to emergencies. 

 

2

 An area with an atmosphere that will cause irreversible adverse health effects or impair an individual’s 

ability to escape is “immediately dangerous to life and health,” according to the Occupational Safety and 

Health Administration Act, 29 Code of Federal Regulations 1910 (Standard Number 1910.134). 
RESULTS

4 REPORT NO. IG-08-027 

Specifically, when ICS is not properly implemented during an incident, the chain of 

command and lines of communication can become confused, increasing the risk of 

injury for responders and other personnel, as well as increasing the risk of damage to 

NASA assets. During at least two of the emergencies that we reviewed, that 

confusion could have resulted in serious injury to the responders and further damage 

to Glenn assets. 

Glenn’s Emergency Response System 

Glenn’s emergency response system is initiated when the Emergency Dispatch Center is 

notified of an alarm or receives a 911 call (see Figure 1). The nature of the emergency 

dictates whether the dispatcher contacts only Glenn responders or contacts both Glenn 

responders and local municipalities. 

Figure 1. Flowchart of Glenn’s Emergency Response System 

The dispatcher radios 

the applicable 

responding organizations 

regarding the location 

and type of emergency. 

Based on the information 

provided, the dispatcher 

designates the emergency 

as confirmed or not 

confirmed. 

The Emergency Dispatch 

Center receives an alarm 

or call that an emergency 

is taking place and 

collects as much 

information as possible 

concerning the 

emergency. 

Confirmed

Not Confirmed 

The dispatcher contacts 

the appropriate Glenn and 

off-site emergency 

response personnel and 

records all information 

relevant to the emergency. 

The responders notify 

dispatch upon arrival 

at the emergency. 

The responders radio 

the dispatcher 

regarding the details 

and their assessment 

of the emergency and, 

if necessary, request 

additional support 

from the local fire 

department and/or the 

ERT. 
RESULTS

REPORT NO. IG-08-027 5 

Regardless of the type of emergency, generally the Glenn first responders are the first to 

arrive on scene and, as such, assume the Incident Commander role until relieved by a 

more qualified authority. As initial Incident Commander, the first responders direct the 

initial emergency response and mitigation activities, which according to the ICS and the 

Glenn EPP consist of 

• providing immediate response to the scene; 

• assessing the situation; 

• notifying the Emergency Dispatch Center if Glenn or municipality resources are 

needed; 

• evacuating the area, if necessary; and 

• establishing a command post and notifying the dispatcher of its location. 

Once relieved by a more qualified authority (such as a fire chief in the case of a fire), the 

first responders are required to provide support to the new Incident Commander. 

ICS Noncompliance 

We reviewed Glenn’s response to 10 emergencies during FYs 2005 through 2007 (listed 

in Table 1). We selected those emergencies from the Incident Reporting Information 

System (IRIS), NASA’s database for recording mishaps.3

 Mishap classifications range 

from a Type A Mishap, which is the most severe, to a Close Call, which is the least 

severe. To cover the spectrum of Glenn emergencies, our sample selection included at 

least one emergency from each mishap classification (see Appendix A for details of our 

sampling plan). 

 

3

 NASA defines a mishap as an unplanned event that results in injury to personnel or damage to property. 

NASA categorizes mishaps based on the severity of injury to personnel or total cost of damage to 

property. 
RESULTS

6 REPORT NO. IG-08-027 

Table 1. Emergencies Selected for Review 

Date Emergency IRIS Number Classification 

June 13, 2007 exterior building fire 2007-164-00005 Type C Mishap 

May 4, 2007 interior building fire 2007-124-00010 Close Call 

April 5, 2007 exterior gas line rupture 2007-096-00019 Close Call 

July 25, 2006 construction site injury 2006-206-00011 Type B Mishap 

April 6, 2006 interior chemical release 2006-097-00002 Type D Mishap 

January 9, 2006 interior tunnel fire 2006-010-00001 Type A Mishap 

November 7, 2005 employee injury 2005-340-00011 Close Call 

July 27, 2005 low-oxygen alarm 2005-209-00003 Close Call 

March 16, 2005 mercury spill 2005-097-00005 Close Call* 

March 9, 2005 fire and explosion 2005-069-00008 Type C Mishap 

* IRIS classified this emergency as “First Aid,” which is not required to be recorded in IRIS. As such, we 

considered this a “Close Call.” 

During each of the 10 emergencies that we reviewed, the Glenn first responders failed to 

adequately implement ICS. Specifically, the responders failed to adequately assess the 

incident from a safe distance, implement appropriate emergency notification procedures, 

isolate and deny entry, use appropriate personal protective equipment, share critical 

information with responding municipalities, or fully document all emergency response 

activities. 

Safe Approach and Assessment. During the July 27, 2005, low-oxygen alarm and the 

March 9, 2005, fire and explosion, Glenn first responders failed to maintain a safe 

distance from the emergency while performing their initial assessment. ICS requires 

responders to assess the emergency from a safe distance, which is typically upwind and 

upslope. The overall priorities when assessing an emergency and determining the 

appropriate level of response are (1) life safety, including the safety of the responders; 

(2) incident stabilization; and (3) property preservation. At Glenn, this initial assessment 

is reported to the Emergency Dispatch Center, along with a request for municipality 

assistance if needed. 

During the initial assessment of the July 27, 2005, low-oxygen alarm, the Glenn 

responders failed to keep a safe distance from an oxygen-deficient atmosphere when they 

entered a building without adequate respiratory protection. Specifically, the first 

responders entered two rooms in which the percentage of oxygen had dropped to unsafe 

levels due to a nitrogen leak. Any imbalance or displacement of oxygen by nitrogen 

within a given space can pose an asphyxiation hazard and because nitrogen is both 
RESULTS

REPORT NO. IG-08-027 7 

odorless and tasteless, unprotected victims have little or no warning of exposure until 

they collapse from the lack of oxygen. In this instance, the first responders escaped 

injury only because the nitrogen (which is heavier than oxygen) had not reached the 

breathing level (mouth and nose) of the responders. 

The Glenn responders also failed to keep a safe distance from the March 9, 2005, fire and 

explosion. During the initial response, the first responders failed to assess the incident 

from a safe distance and instead entered the area where the fire and explosion occurred. 

Shortly after they entered that area, a second explosion occurred; the concussion from the 

second explosion was significant enough to cause temporary hearing loss to one of the 

responders. 

Emergency Notification Protocol. During five emergencies—the April 5, 2007, 

exterior gas line rupture; the July 25, 2006, construction site injury; the January 9, 2006, 

interior tunnel fire; the July 27, 2005, low-oxygen alarm; and the March 16, 2005, 

mercury spill—the Glenn responders failed to initiate an emergency notification protocol 

based on the severity and type of the emergency. In accordance with ICS and the 

Center’s EPP, once an emergency is declared and an Incident Commander and command 

post initiated, the Incident Commander should contact dispatch to ensure that all required 

resources, including personnel and equipment, are notified and en route to the 

emergency. That emergency notification protocol includes notifying Glenn’s ERT during 

certain types of Center emergencies. Notification of the ERT is vitally important because 

of the organizational and functional expertise the ERT provides to the Incident 

Commander. For the 10 emergencies that we reviewed, Table 2 illustrates those 

instances in which the ERT should have been notified but was not. 
RESULTS

8 REPORT NO. IG-08-027 

Table 2. Emergencies Requiring ERT Notification

Emergency 

ERT 

Notification Criteria

April 5, 2007 

(exterior gas 

line rupture) 

July 25, 2006 

(construction 

site injury) 

Jan. 9, 2006 

(interior 

tunnel fire) 

July 27, 2005 

(low-oxygen 

alarm) 

March 16, 

2005 

(mercury spill) 

Type A, B, or C Mishap X X 

Municipality response 

requested X X 

Center or building 

evacuation or closure X 

Major power failure X 

Fire or explosion X 

Medical emergency 

requiring transport to 

hospital 

X 

Hazardous material release 

and chemical spill X X X X 

Hazard Isolation. During three emergencies—the July 25, 2006, construction site 

injury; the July 27, 2005, low-oxygen alarm; and the March 9, 2005, fire and explosion—

Glenn first responders failed to “isolate and deny entry”4 to the incident scene, including 

areas that were “immediately dangerous to life and health.” ICS requires the Incident 

Commander to ensure the safety of personnel, including emergency responders, by 

isolating the scene, denying unnecessary access, and preventing harmful exposures. 

Under ICS, isolation—securing the scene—is the first step in the protective action 

process and is implemented to prevent injury to the emergency responders and to 

establish control over the emergency scene. The Incident Commander is responsible for 

ensuring that all response activities are focused on preventing further injury to personnel 

or damage to property. 

 

4

 The U.S. Department of Transportation’s Emergency Response Guidebook defines “isolate hazard and 

deny entry” as a means to keep personnel away from hazardous environments. 
RESULTS

REPORT NO. IG-08-027 9 

During the July 25, 2006, construction site injury, first responders failed to secure the 

scene of the incident and to clear the area of nonessential personnel. In this incident, a 

construction worker was seriously injured when he fell from an extension ladder. 

According to two Glenn Safety Engineers who responded to the incident, the area was 

not fully cleared of nonessential personnel until after the arrival of the fire department. 

In this incident, only those individuals directly involved in providing care to the injured 

worker should have been permitted to remain in the area. The Incident Commander 

should have immediately isolated the area surrounding the victim to ensure the safety of 

personnel, to provide sufficient space that would allow the responders to provide care, 

and to protect the victim’s privacy. 

The incident scene was also not secured during the July 27, 2005, low-oxygen alarm and 

the March 9, 2005, fire and explosion. In both cases, the first responders failed to isolate 

and deny entry into the area around the incident and unnecessarily exposed themselves to 

a situation that could have been immediately dangerous to life and health. 

Respiratory Protection. During the 

January 9, 2006, interior tunnel fire and the 

July 27, 2005, low-oxygen alarm, the Glenn 

first responders failed to use appropriate 

respiratory protective equipment when 

responding to a potentially hazardous 

environment. ICS requires all emergency 

responders to use appropriate personal 

protective equipment for the tasks they are to 

perform. 

Glenn’s “Occupational Health Programs 

Manual,” Chapter 4, “Respiratory Protection 

Program,” February 2007,5

 addresses this ICS requirement by specifying the required 

equipment. A self-contained breathing apparatus (SCBA), as shown in Figure 2, should 

be used in an unknown, oxygen-deficient, or immediately dangerous to life and health 

atmosphere. Glenn’s Manual further requires that personnel be trained in the use and 

limitations of an SCBA before using it. 

In the January 9, 2006, interior tunnel fire, the Glenn first responders and the City of 

Brook Park’s Fire Chief were operating under a unified command system.6

 During this 

emergency, a Brook Park firefighter and two Glenn employees were permitted to enter a 

building filled with dense smoke without respiratory protective equipment. The fire, 

which had originated in an electrical splicing chamber inside an underground utility 

 

5

 The Manual is continually updated; respiratory requirements were in effect at the time of the 

emergencies. 

6

 Under ICS, a unified command system is when two or more agencies work together to manage an 

incident. 

Figure 2. Responder Using SelfContained Breathing Apparatus
RESULTS

10 REPORT NO. IG-08-027 

tunnel, had resulted in the propagation of dense smoke throughout the tunnel and into 

adjoining buildings. As such, anyone entering the tunnel or buildings should have been 

wearing personal protective equipment, including respiratory protection to prevent 

asphyxiation. The unified command also allowed one of the Glenn first responders to 

borrow an SCBA from one of the responding fire departments and, on two separate 

occasions, he accompanied the firefighters into the smoke-filled buildings. The first 

responder did not have the authority, training, or certification to use the SCBA. Without 

such authority, training, and certification, the first responder may not have been aware of 

the limits of the SCBA, which could have resulted in injury to him and the other 

responders. 

During the July 27, 2005, low-oxygen alarm, the first responders entered a building 

without appropriate respiratory protection. At the time of this incident, the first 

responders had been removed from the Center’s respiratory protection program and, as a 

result, did not have access to respiratory protective equipment such as an SCBA. 

Because the first responders believed that they were expected to respond to potentially 

oxygen-deficient atmospheres, they entered two rooms where the oxygen had been 

reduced to an unsafe level, unnecessarily exposing them to an asphyxiation hazard. 

Information Sharing with Local Municipalities. During four emergencies—the 

June 13, 2007, exterior building fire; the May 4, 2007, interior building fire; the 

January 9, 2006, interior tunnel fire; and the March 9, 2005, fire and explosion—the 

Glenn responders did not share critical information with the responding local fire 

departments. ICS requires responders to establish a process for gathering, sharing, and 

managing all incident-related information. The Glenn EPP addresses this ICS 

requirement by requiring Glenn first responders to provide prefire plans,7

 blueprints, 

maps, and other supporting documentation to responding fire and emergency personnel 

for use during on-site emergencies. However, during these four emergencies, the Glenn 

first responders did not have access to all necessary information and, therefore, could not 

provide it to the responding fire departments. Although the first responders did carry 

prefire plans in their vehicles, they did not carry or have electronic access to utility maps, 

evacuation plans, chemical inventory lists, or Material Safety Data Sheets.8

 Further, the 

prefire plans that the Glenn responders did have were either not provided to the 

responding firefighters or the plans failed to include relevant information. If 

appropriately designed and implemented, prefire plans are invaluable to responding fire 

departments because the plans identify hazards that could potentially impact firefighter 

safety. For each of the four emergencies, the responding firefighters entered a building 

without having crucial knowledge of the building layout and the location of potential 

hazards, which significantly increased their risk of injury. 

 

7

 Title 15, United States Code, Chapter 49, Section 2227, “Fire Safety Systems in Federally Assisted 

Buildings,” defines a “prefire plan” as specific plans for firefighting activities at a property or location. 

8

 Material Safety Data Sheets contain information concerning the properties and hazards of chemicals used 

and stored in the workplace, including the engineering and personal protective equipment necessary to 

protect personnel from hazardous exposure. 
RESULTS

REPORT NO. IG-08-027 11 

Inconsistent and Incomplete Documentation. The response documentation for all 

10 emergencies that we reviewed was inconsistent and incomplete. ICS requires 

responders to develop an Incident Action Plan and to maintain accurate and complete 

files to document the major steps taken during an emergency response. ICS also requires 

responders to retain all emergency-related documentation for legal, analytical, and 

historical purposes. 

The Glenn EPP implements the ICS requirement by requiring the dispatcher to maintain a 

log of all emergency actions taken. However, the logs did not always contain sufficient 

information or were in conflict with other response documentation. For example, during 

the May 4, 2007, interior building fire, the notification and response times recorded in the 

Emergency Dispatch Log were different from the times recorded in the Security Log and 

the Brook Park Fire Department report. 

We also noted that the Emergency Dispatch Logs did not always include 

• notification of the emergency to security personnel and the Brook Park Fire 

Department; 

• information regarding who assumed the initial role of Incident Commander or the 

next person who assumed the role of Incident Commander; 

• arrival times of the first responders, local fire departments, and emergency 

medical services; and 

• the time the emergency was terminated. 

The Glenn EPP also requires the first responders to provide daily reports to the Safety, 

Health, and Environmental Division regarding their response activities, but does not 

provide guidance as to the content of the reports. During the July 25, 2006, construction 

site injury, the first responder report simply stated that a male was observed lying on the 

ground, that Safety Office personnel had been requested, and that the fire department had 

transported the victim to a local hospital. The report failed to provide pertinent 

information regarding the emergency, such as the extent of the victim’s injuries, that the 

area was not immediately cleared of nonessential personnel, or that the Brook Park Fire 

Department had trouble hoisting the person out of the construction site. An accurate 

record of such information is critical for historical purposes and for effectively recording 

“lessons learned.” 

Roles and Responsibilities Not Clearly Defined 

The Glenn responding organizations did not clearly define the roles and responsibilities 

for the personnel required to implement ICS during on-site emergencies. Glenn guidance 

regarding emergency response is under the purview of the Office of Security 

Management and Safeguards. Within that office is the Emergency Management 

Coordinator, who is responsible for developing the Center’s EPP. The EPP provides 
RESULTS

12 REPORT NO. IG-08-027 

general guidance regarding roles and responsibilities of first responders as well as other 

Glenn emergency responders. We do not expect the EPP to contain more than general 

guidance; however, the EPP should require that the responder organizations develop 

supplemental guidance containing specific information concerning roles and 

responsibilities during an emergency. None of the responder organizations had such 

supplemental guidance. 

For example, Glenn first responders report to the Safety Branch of the Safety and 

Mission Assurance Directorate’s Safety, Health, and Environmental Division. However, 

the Safety Branch had not instituted a standard operating procedure to define first 

responders’ tactical actions, lines of authority, qualifications, or use of personal 

protective equipment. In addition, the first responders’ position descriptions did not 

include details concerning responsibilities, limitations, and performance evaluation 

standards associated with first responder duties. The other response organizations 

apparently had not been made aware of those responsibilities and limitations either 

because in two of the emergencies—the July 27, 2005, low-oxygen alarm and the 

January 9, 2006, interior tunnel fire—the Emergency Dispatch Center dispatched the first 

responders to potentially oxygen-deficient atmospheres after the first responders had 

been removed from the Center’s respiratory protection program. 

Memorandums of Understanding Not Prepared 

Because Glenn does not have the necessary resources to effectively mitigate major 

emergencies, the Center is dependent on off-site emergency responders. To ensure that 

all emergency responders properly coordinate and integrate their resources during an 

emergency, Centers are required to establish MOUs with the off-site responding 

organizations. Specifically, paragraph 11.3 of NASA Standard 8719.11, “Safety 

Standard for Fire Protection,” August 2000, requires Centers to have written agreements 

when an off-site, non-NASA fire service organization provides fire suppression, fire 

rescue, emergency medical services, and hazardous materials response. 

This is a repeat finding, as that lack of MOUs was cited in two safety audits conducted by 

the NASA Office of Safety and Mission Assurance, the first in December 2005 and the 

second in May 2008. In response to the December 2005 safety audit, Glenn indicated 

that an MOU with the City of Brook Park was 40 percent complete and that the projected 

completion date was July 30, 2006. However, as of the date of this report (2 years later), 

Glenn had not finalized that MOU. 

Increased Risks to Personnel, Property, and Mission 

Glenn is continuously exposed to potential hazards and emergencies due to its mission 

and operations, as well as acts of nature. These emergencies could result in the loss of 

life, serious injury, or property damage that could negatively affect NASA’s operations 
RESULTS

REPORT NO. IG-08-027 13 

and missions. To manage its risks, Glenn should have a clear process for responding to 

on-site emergencies that follows a strict chain of command where subordinate responders 

report through that chain to the on-scene Incident Commander. The strict adherence to a 

chain of command reduces the potential for miscommunication and confusion. Glenn’s 

lack of clearly defined roles, responsibilities, and lines of authority for its first 

responders, along with the absence of MOUs with off-site responding organizations, has 

negatively affected the Center’s ability to respond effectively to emergencies. During at 

least two of the emergencies that we reviewed—the March 9, 2005, fire and explosion 

and the July 27, 2005, low-oxygen alarm—the lack of defined roles and responsibilities 

could have resulted in serious injury to the responders and other NASA personnel and 

further damage to Glenn assets. 

Other Matters of Interest 

During our review of Glenn’s emergency response system, we visited 10 facilities on 

Glenn’s main campus (Lewis Field) that should have had emergency action plans. Of the 

10 facilities, 6 did not have plans and 3 had plans that were missing critical elements 

required by Federal and Glenn guidance, such as evacuation routes (primary and 

secondary), identification of evacuation monitors, and post-evacuation assembly 

locations where accountability could be determined for all personnel. 

The Occupational Safety and Health Administration Act, 29 Code of Federal 

Regulations 1910 (Standard Number 1910.38), requires employers to have a written 

emergency action plan for each location with 10 or more employees. The emergency 

action plan should include procedures for emergency evacuations, illustrate the primary 

and secondary routes of egress,9

 and define a process for accounting for all employees. 

In addition, the Glenn Safety Manual, Chapter 27, “Building Evacuation Plan Program,” 

requires the development and implementation of an emergency action plan for each 

building. The plans must be developed and implemented in accordance with each 

location’s unique operational environment and should be prominently posted in each 

facility and work location. 

 

9

 The Glenn Safety Manual defines emergency egress as the process by which a continuous and 

unobstructed way of exit travel is maintained from any point in a building to a predetermined safe 

location. Typically, this is accomplished by overlaying arrows onto facility maps pointing in the 

direction of travel to the building exits. 
RESULTS

14 REPORT NO. IG-08-027 

Recommendations, Management’s Response, and Evaluation of 

Management’s Response 

Recommendation 1. We recommended that the Chief, Office of Security Management and 

Safeguards, review the roles and responsibilities assigned to each of the responding 

organizations, to include the off-site organizations, and ensure that the responders are 

qualified to assume those roles and responsibilities and can effectively and timely respond to 

Glenn emergencies. The Chief, Office of Security Management and Safeguards, should 

revise the EPP to reflect any changes in roles and responsibilities based on the review, if 

necessary. 

Management’s Response. The Glenn Director concurred, stating that the Glenn 

Emergency Management Coordinator will review the roles and responsibilities of on-site 

and off-site emergency responders to ensure they are qualified and authorized to perform 

those responsibilities and revise the Center EPP to reflect changes in roles and 

responsibilities by November 30, 2009. Specifically, he stated that the Emergency 

Management Coordinator will examine the Glenn EPP and Safety Manual to identify 

specified and implied roles and responsibilities. In addition, the review will include an 

assessment of 

• composition and roles of the ERT; 

• coordination with partner agencies; and 

• training. 

Evaluation of Management’s Response. Management’s proposed actions are 

responsive. The recommendation is resolved and will be closed upon completion and 

verification of management’s corrective action. 

Recommendation 2.a. We recommended that the Chief, Office of Security Management 

and Safeguards, revise the EPP to require that the Glenn organizations with personnel 

expected to respond to emergencies develop standard operating procedures that, at a 

minimum, include a clear definition of specific roles, responsibilities, authority, and 

limitations. 

Management’s Response. The Glenn Director concurred, stating that the Chief, Office 

of Security Management and Safeguards, in conjunction with the Director of Center 

Operations, the Director of Safety and Mission Assurance, and the Emergency 

Management Coordinator, will analyze and determine the best organization for 

emergency response and incorporate the results into the Center EPP by July 30, 2009. 

Specifically, he stated that the revision will incorporate standard operating procedures 

that include clear definition of specific roles, responsibilities, authorities, and limitations. 

Additionally, efforts are underway to incorporate all Center emergency response tasks as 

a function of the ERT, which will allow better utilization of the ICS principles. 
RESULTS

REPORT NO. IG-08-027 15 

Evaluation of Management’s Response. Management’s proposed actions are 

responsive. The recommendation is resolved and will be closed upon completion and 

verification of management’s corrective action. 

Recommendation 2.b. We recommended that the Chief, Office of Security Management 

and Safeguards, revise the EPP to require that the Glenn Emergency Management 

Coordinator review and approve the organizational level standard operating procedures to 

eliminate any conflict between the responding organizations and the EPP. 

Management’s Response. The Glenn Director concurred, stating that the Chief, Office 

of Security Management and Safeguards, in conjunction with the Director of Center 

Operations, the Director of Safety and Mission Assurance, and the Emergency 

Management Coordinator, will analyze and determine the best organization for 

emergency response and incorporate the results into the Center EPP by July 30, 2009. 

Specifically, the revision of the EPP will require the Emergency Management 

Coordinator to review and approve the standard operating procedures of the ERT and all 

responding organizations to ensure there are no conflicts. 

Evaluation of Management’s Response. Management’s proposed actions are 

responsive. The recommendation is resolved and will be closed upon completion and 

verification of management’s corrective action. 

Recommendation 2.c. We recommended that the Chief, Office of Security Management 

and Safeguards, revise the EPP to require that the Glenn Emergency Management 

Coordinator reconciles all emergency response reports to ensure the reports are accurate and 

consistent. 

Management’s Response. The Glenn Director concurred, stating that the Chief, Office 

of Security Management and Safeguards, in conjunction with the Director of Center 

Operations, the Director of Safety and Mission Assurance, and the Emergency 

Management Coordinator, will analyze and determine the best organization for 

emergency response and incorporate the results into the Center EPP by July 30, 2009. 

Specifically, the revision of the EPP will require the Emergency Management 

Coordinator to reconcile all emergency response reports to ensure that the information is 

accurate. 

Evaluation of Management’s Response. Management’s proposed actions are 

responsive. The recommendation is resolved and will be closed upon completion and 

verification of management’s corrective action. 

Recommendation 3. We recommended that the Glenn Director, in coordination with the 

Emergency Management Coordinator, ensure that MOUs are established with non-NASA 

organizations that provide fire suppression, fire rescue, emergency medical services, police, 

and hazardous chemicals and materials response. The MOUs, at a minimum, should include 

the delineation of roles, responsibilities, jurisdiction, and authority of all non-NASA 
RESULTS

16 REPORT NO. IG-08-027 

organizations expected to respond to Glenn emergencies and a requirement that ICS is 

implemented during all Glenn emergencies. 

Management’s Response. The Glenn Director concurred, stating that the Emergency 

Management Coordinator, in cooperation with the Chief, Security Management and 

Safeguards Office; the Chief, Safety, Health, and Environmental Division; the Office of 

Chief Counsel; and the Center Director’s Office, will initiate negotiations to establish 

MOUs with adjoining or jurisdictional organizations that provide fire suppression, fire 

rescue, emergency medical services, police, and hazardous chemicals and materials 

response by December 10, 2009. He stated that negotiations will take place with the City 

of Brook Park, the City of Fairview Park, Perkins Township, and the Cleveland Hopkins 

International Airport and that the MOUs will require the implementation of ICS during 

all Glenn emergencies. In addition, Glenn is negotiating with Hopkins Airport and the 

City of Brook Park to establish a Joint Fire Station near Glenn. 

Evaluation of Management’s Response. Management’s proposed actions are 

responsive. The recommendation is resolved and will be closed upon completion and 

verification of management’s corrective action. 

Recommendation 4. We recommended that the Chief, Glenn Safety, Health, and 

Environmental Division, ensure that a written emergency action plan is prepared for each 

facility at Lewis Field. The plan should address the evacuation procedures, show the 

primary and secondary routes of egress, and define a process for accounting for all 

employees. The plan should be prominently posted in each facility and work location. 

Management’s Response. The Glenn Director concurred, stating that the Safety, 

Health, and Environmental Division will develop a new emergency action plan for each 

Glenn facility by April 23, 2009. He also stated that the plans will be audited to ensure 

that each plan incorporates evacuation procedures, egress routes, and employee 

accountability. In addition, the plans will be posted on the Center’s intranet and in a 

prominent location in each building. 

Evaluation of Management’s Response. Management’s proposed actions are 

responsive. The recommendation is resolved and will be closed upon completion and 

verification of management’s corrective action. 
APPENDIXES

REPORT NO. IG-08-027 17 

APPENDIX A 

Scope and Methodology 

We performed this review from July 2007 through July 2008 in accordance with 

generally accepted government auditing standards. Those standards require that we plan 

and perform the review to obtain sufficient, appropriate evidence to provide a reasonable 

basis for our findings and conclusions based on our review objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and conclusions based 

on our review objectives. 

We obtained, reviewed, and analyzed Federal, NASA, and Glenn guidance pertaining to 

emergency response, to include HSPD-5, the Occupational Safety and Health 

Administration Act, NASA Standard 8719.11, NPR 8715.2, and the Glenn EPP. 

To assess ICS implementation during Glenn emergencies, we selected 10 emergencies 

from the IRIS database and analyzed applicable documentation for the response 

activities. That documentation included Emergency Dispatch Logs, first responder daily 

reports, Brook Park Fire Department reports, Mishap Investigation Board reports, and 

Security Logs. 

We interviewed the Glenn Emergency Management Coordinator; the first responders; the 

Fire Protection Engineer; the Chief, Safety, Health, and Environmental Division; an 

Industrial Hygienist; and the Captain of Glenn Security. We also interviewed personnel 

from local fire departments. 

To determine whether the emergency response system had adequate oversight, we 

reviewed Glenn’s post-incident critique reports. We also evaluated reviews and audits 

conducted by NASA’s Office of Safety and Mission Assurance and determined whether 

corrective actions were taken in response to any findings and recommendations and the 

extent of follow-up performed to ensure that corrective actions were taken. 

Sampling Plan. We obtained the population of Glenn emergencies for FYs 2005, 2006, 

and 2007 from the NASA IRIS database. The total population of Glenn emergencies for 

the 3-year period was 572: 189 in 2005, 175 in 2006, and 208 in 2007. 

We selected 10 Glenn emergencies from the IRIS database based on a stratification of 

cases by year, then by mishap classification (Types A, B, C, and D Mishaps and Close 

Calls). To cover the spectrum of emergencies, we included at least one emergency from 

each mishap classification. Of the 572 emergencies, two were serious (categorized as 

Type A and Type B Mishaps). We included those two emergencies in our sample and 

then selected eight other emergencies, considering incident description, mishap 
APPENDIX A 

18 REPORT NO. IG-08-027 

classification, and date of occurrence. Our review of Glenn’s response to these 

10 emergencies forms the basis of our results. 

Use of Computer-Processed Data. We used computer-processed data from IRIS to 

identify the population of Glenn emergencies relative to safety issues. We did not 

evaluate whether IRIS contained all of Glenn’s reportable incidents; however, we believe 

the data was adequate for selecting emergencies for more detailed review. 

We identified some errors within the IRIS database and informed Glenn management, 

who agreed to correct the errors. The errors within IRIS did not affect the results of our 

review.

Review of Internal Controls 

We reviewed internal controls for the Glenn emergency response process, including 

policies and procedures and oversight by Glenn’s Chief, Office of Security Management 

and Safeguards, and Chief, Safety, Health, and Environmental Division. We identified 

internal control weaknesses in Glenn’s emergency response process, which are discussed 

in the finding. Our recommendations, if implemented, will improve the controls over 

Glenn’s emergency response process. 

Prior Coverage 

During the last 5 years, the NASA Office of Safety and Mission Assurance has issued 

two reports concerning Glenn’s emergency preparedness. The NASA Office of Inspector 

General has also issued two reports that discuss safety issues at Glenn. NASA Office of 

Inspector General reports may be accessed over the Internet at 

http://oig.nasa.gov/audits/reports/FY08/. 

NASA Office of Inspector General 

“Effective Inspection Program Key to Improving Laboratory Safety at Glenn Research 

Center” (IG-07-032, September 24, 2007) addressed laboratory safety and the process for 

reviewing, approving, and maintaining safety permits for Glenn laboratory operations. 

“NASA’s Implementation of the National Incident Management System” (IG-06-016, 

August 29, 2006) found that each Center’s EPP, including Glenn’s, did not fully comply 

with NIMS requirements. 
APPENDIX A 

REPORT NO. IG-08-027 19 

NASA Office of Safety and Mission Assurance 

“NASA Institutional/Facilities/Operational Safety Audit of Glenn Research Center” 

(May 29, 2008) found a noncompliance issue previously reported in their December 14, 

2005, report regarding no written agreement with the Brook Park Fire Department or 

Hopkins International Airport Fire Department for non-aircraft emergencies. 

“NASA Institutional/Facilities/Operational Safety Audit of Glenn Research Center” 

(December 14, 2005), found that emergency preparedness was satisfactory overall; 

however, the Center needed to ensure that all first responders, managers, and employees 

were properly trained to meet the challenges of threats and disasters, and the Center 

needed to establish an MOU with the City of Brook Park for fire protection services. 
APPENDIX B 

20 REPORT NO. IG-08-027 

MANAGEMENT COMMENTS
APPENDIX B 

REPORT NO. IG-08-027 21 
APPENDIX B 

22 REPORT NO. IG-08-027 
APPENDIX B 

REPORT NO. IG-08-027 23 
APPENDIX B 

24 REPORT NO. IG-08-027 
APPENDIX C 

REPORT NO. IG-08-027 25 

REPORT DISTRIBUTION

National Aeronautics and Space Administration 

Administrator 

Deputy Administrator 

Chief of Staff 

Chief, Safety and Mission Assurance 

Director, Glenn Research Center 

Director of Center Operations 

Chief, Office of Security Management and Safeguards 

Emergency Management Coordinator 

Director, Safety and Mission Assurance Directorate 

Chief, Safety, Health, and Environmental Division 

Non-NASA Organizations and Individuals 

Office of Management and Budget 

Deputy Associate Director, Energy and Science Division 

Branch Chief, Science and Space Programs Branch 

Government Accountability Office 

Director, Defense, State, and NASA Financial Management, Office of Financial 

Management and Assurance 

Director, NASA Issues, Office of Acquisition and Sourcing Management 

Congressional Committees and Subcommittees, Chairman and 

Ranking Member 

Senate Committee on Appropriations 

Subcommittee on Commerce, Justice, Science, and Related Agencies 

Senate Committee on Commerce, Science, and Transportation 

Subcommittee on Space, Aeronautics, and Related Sciences 

Senate Committee on Homeland Security and Governmental Affairs 

House Committee on Appropriations 

Subcommittee on Commerce, Justice, Science, and Related Agencies 

House Committee on Oversight and Government Reform 

Subcommittee on Government Management, Organization, and Procurement 

House Committee on Science and Technology 

Subcommittee on Investigations and Oversight 

Subcommittee on Space and Aeronautics 

Major Contributors to the Report: 

Raymond Tolomeo, Director, Mission Programs and Projects Directorate 

Ronald Yarbrough, Project Manager 

Dennis Clay, Team Lead 

Lynette Westfall, Auditor 

Elizabeth Shifflett, Report Process Manager 

REPORT NO. IG-08-027 27 
SEPTEMBER 3, 2008 

REPORT No. IG-08-027 

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