IG-02-018

AUDIT 

REPORT NASA OVERSIGHT OF UNITED SPACE 

ALLIANCE’S SAFETY PROCEDURES AT THE 

JOHN F. KENNEDY SPACE CENTER 

June 24, 2002 

 National Aeronautics and 

Space Administration

OFFICE OF INSPECTOR GENERAL
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Acronyms 

GSE Ground Support Equipment 

PFA Plastic Films, Foams, and Adhesive tapes 

SFOC Space Flight Operations Contract 

SFOP Safety Operating Procedure 

SSP Space Shuttle Program

SAA System Assurance Analysis 

TMR Technical Management Representative 

USA United Space Alliance 
June 24, 2002 

W 

TO: Distribution

FROM: HQ/W/Assistant Inspector General for Audits 

SUBJECT: Final Report on Audit of NASA Oversight of United Space Alliance’s 

Safety Procedures at the John F. Kennedy Space Center 

 Assignment Number A-00-041-02 

Report Number IG-02-018 Redacted Report∗

The subject final report is provided for your information and use. Please refer to the 

Executive Summary for the overall audit results. Our evaluation of your response is 

incorporated into the body of the report. Although you nonconcurred with two of the 

seven recommendations, we consider your planned corrective actions responsive to all of 

the recommendations. Recommendations 2 and 6 are considered closed for reporting 

purposes. For the remaining recommendations, please notify us when action has been 

completed on them, including the extent of testing performed to ensure corrective actions 

are effective. The final report distribution is in Appendix G. 

We appreciate the courtesies extended to the audit staff. If you have questions concerning 

the report, please contact Ms. Sandra Massey, Program Director, Safety and Technology 

Audits, at (321) 867-4057, or Mr. Karl Allen, Audit Program Manager, at (202) 358-2595. 

[original signed by]

Alan J. Lamoreaux 

Enclosure 

Distribution:

HQ/M/Associate Administrator for Space Flight

HQ/Q/Associate Administrator for Safety and Mission Assurance 

JSC/AA/Director, Lyndon B. Johnson Space Center 

KSC/AA/Director, John F. Kennedy Space Center 

 ∗ We have redacted portions of this report due to references to sensitive information. The redacted passages 

do not affect the validity of this report or management’s response. 
2 

cc: 

HQ/AI/Associate Deputy Administrator 

HQ/B/Acting Chief Financial Officer 

HQ/B/Comptroller 

HQ/BF/Director, Financial Management Division 

HQ/G/General Counsel 

HQ/H/Assistant Administrator for Procurement 

HQ/JM/Director, Management Assessment Division 

HQ/QS/Director, Safety and Risk Management Division
Contents 

Executive Summary, i 

Introduction, 1 

Findings and Recommendations, 2

Finding A. Shuttle Safety Responsibilities at Kennedy, 2 

Finding B. Safety of Shuttle Integrated Logistics, 6 

Finding C. Shuttle Ground Support Equipment Safety Analyses, 9 

Finding D. Safety Procedures for Payload Installation and 

 Removal, 14

Appendix A – Objectives, Scope, and Methodology, 20

Appendix B – Summary of Prior Audit Coverage, 22

Appendix C – Safety Responsibilities Subdelegated to the Integrated 

Logistics Technical Management Representative, 24

Appendix D – Sample Results for Ground Support Equipment 

Undergoing Analysis, 25 

Appendix E – Audit Trail of United Space Alliance Safety 

 Procedures, 27

Appendix F – Management’s Response, 28 

Appendix G – Report Distribution, 33 
NASA Office of Inspector General 

IG-02-018 June 24, 2002 

 A-00-041-02 

NASA Oversight of United Space 

Alliance’s Safety Procedures at the 

John F. Kennedy Space Center 

Executive Summary 

Background. The Office of Inspector General has completed an audit1 of the United 

Space Alliance’s (USA’s) safety procedures under NASA’s Space Flight Operations 

Contract (SFOC).2

 USA, a joint venture of The Boeing Company and Lockheed-Martin, 

is one of five prime contractors supporting the Space Shuttle Program (SSP). USA is 

responsible for the contracted tasks associated with the processing and flight preparation 

of the Space Shuttle fleet. USA's work affects the safety of NASA's astronauts; the 

Space Shuttle orbiters; and space flight personnel, hardware, and equipment. The Space 

Shuttle Program Office located at the Lyndon B. Johnson Space Center (Johnson) is 

responsible for managing the SFOC and the SSP. SSP operations occur primarily at 

Johnson, the John F. Kennedy Space Center (Kennedy), and the George C. Marshall 

Space Flight Center. We reviewed USA’s implementation of the SFOC safety 

requirements for the SSP related to ground operations3

 and integrated logistics4 at 

Kennedy, as well as NASA’s oversight5

 of USA's safety procedures. 

 1

 This audit was the third in a series of audits of USA’s safety procedures under the Space Flight 

Operations Contract. In our report IG-01-034, “Controls Over the Use of Plastic Films, Foams, and 

Adhesive Tapes In and Around the Space Shuttle Orbiter Vehicles,” dated August 31, 2001, we identified a 

lack of control over the use of plastic films, foams, and adhesives tapes in and around the Space Shuttle 

orbiter vehicles that created a potential safety hazard to personnel, the orbiter vehicles, and other flight 

hardware and equipment. In report IG-01-017, “Space Shuttle Program Management Safety Observations,”

dated March 23, 2001, we identified weaknesses in NASA's management control structure for providing

oversight of USA’s safety operations under the SFOC. The results of both audits are summarized in

Appendix B of the report. 2

 NASA awarded the SFOC to USA of Houston, Texas, on September 26, 1996. The SFOC is a cost-plusaward-fee/incentive fee/performance fee type contract and has a period of performance from

October 1, 1996, through September 30, 2002. The contract includes two, 2-year option periods, which 

potentially extends the period of performance through September 30, 2006. As of March 8, 2002, the total

contract cost plus fee was estimated at $9.7 billion. 3

 Ground operations, one of the two major SFOC components located at Kennedy, consist of vehicle 

integration, payload installation, launch preparation and execution, and post launch operations. 4

 Integrated logistics consist of operations such as spare parts, maintenance, and warehousing for the Space 

Shuttle. 5

 The SFOC defines oversight as day-to-day management, review, and approval of USA’s operations. 
Objectives. The overall audit objective was to evaluate USA’s safety procedures for 

NASA's SFOC. The specific objectives related to this report were to determine whether: 

• safety responsibilities between USA and NASA were clearly defined and 

• NASA was performing effective oversight of USA’s safety program.

6

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

Results of Audit. The safety responsibilities between USA and NASA were clear in that 

NASA established all SSP safety requirements, USA implemented those requirements 

through the SFOC, and NASA was fully responsible for the safe launch of the Shuttle. 

However, Kennedy’s procedures for ensuring that USA properly implemented those 

safety requirements were not the same procedures defined in the SFOC. The SFOC 

states that NASA is to provide direct safety oversight of all USA operations. 

Nevertheless, Kennedy did not provide direct safety oversight of USA’s ground 

operations but rather obtained insight7

 into USA’s safety operations through surveillance 

and audits (Finding A). Further, Kennedy did not perform any level of safety oversight 

for integrated logistics, a high-risk area for injuries and mishaps (Finding B). 

Implementing a level of oversight that contradicts that required by the SFOC could lead 

to lapses in safety oversight, increasing the risk of harming personnel and damaging 

Space Shuttle hardware. 

Although USA had developed a detailed safety management system8

 to ensure 

compliance with NASA requirements for the safety of NASA's astronauts; the Space 

Shuttle orbiters; and space flight personnel, hardware, and equipment, we identified two 

areas where USA can further improve safety. USA inappropriately used ground support 

equipment (GSE) 9 at Kennedy prior to completing required analyses to ensure that all

hazards associated with the GSE were properly controlled (Finding C). Additionally, 

there was no evidence that USA performed some critical, required safety procedures for a 

specific operation at Kennedy involving payload removal from an orbiter vehicle 

(Finding D). By using GSE prior to completion of the analyses and by not performing all 

required safety procedures for payload removal, USA may have increased the risk of 

harm to personnel and Shuttle hardware. 

 6 We also addressed this objective in report IG-01-017, “Space Shuttle Program Management Safety 

Observations,” March 23, 2001. In that audit, we evaluated the NASA SSP Program Office’s oversight of

the NASA-wide USA safety program. In this current audit, we evaluated Kennedy’s oversight of USA

safety for ground operations and integrated logistics at Kennedy. 7

 The SFOC defines insight as audit and surveillance of work to a level of detail that provides assurance of

satisfactory work accomplishment. The audits consist of the Kennedy Shuttle Safety Office’s review of 

various USA safety operations to ensure that the operations are in compliance with SSP requirements. The 

Kennedy Shuttle Safety Office performs about 13 audits each year. Some of the audit topics include

USA’s procedures for document control, use of plastic films, and mishap reporting. 8

 USA’s safety management system included a safety and health plan, detailed safety procedures, hazard

analyses, and mishap reporting and investigative procedures. 9

 GSE includes equipment used in ground operations to store, transport, handle, monitor, test, check out, service, 

and communicate with and control aircraft, and to launch vehicles, payloads, and spacecraft. 

ii
NASA has planned six Space Shuttle flights to assemble the International Space Station 

from June 2002 through April 2003. Therefore, prompt management attention to all four 

areas is particularly important to the safety and success of the SSP. 

Recommendations. We recommended that NASA ensure that SFOC safety 

requirements and Kennedy safety procedures are consistent. We also recommended that 

NASA review USA processes for implementing SSP requirements related to the approval 

and use of GSE in critical applications and ensure that USA’s safety procedures for future 

payload installation and removal operations are properly implemented and documented. 

Finally, we recommended that NASA require the Kennedy Shuttle Processing Directorate 

and Shuttle Safety Office to improve procedures for ensuring that USA implements all 

safety requirements associated with safety analyses and payload removals. The complete 

text of management’s response is in Appendix F. 

Management’s Response. NASA concurred with five of the seven recommendations 

and has taken or planned corrective actions that we consider responsive. Although 

NASA nonconcurred with two recommendations, it has planned corrective actions that 

we consider responsive. 

iii
Introduction 

As a prime contractor for NASA’s SSP, USA is responsible for many day-to-day 

operations of the Space Shuttle fleet. USA's work affects the safety of NASA's

astronauts; the Space Shuttle orbiters; and space flight personnel, hardware, and 

equipment. At Kennedy, USA’s specific responsibilities include Space Shuttle 

modification, testing, checkout, and launch and landing activities. Management of the 

SFOC at Kennedy is divided into two components that are separately managed by 

Technical Management Representatives (TMR’s).10 The two components are: 

• ground operations, which includes vehicle integration, payload installation, 

launch preparation and execution, and post launch operations. 

• integrated logistics, which includes repairs, maintenance, spare parts, 

warehousing for the Space Shuttle orbiters, and associated GSE. 

The SFOC Contracting Officer delegated the responsibility for safety oversight of USA 

to the SSP Safety Manager11 who is located at Johnson. The SSP Safety Manager then 

subdelegated safety tasks to the ground operations TMR. Those safety tasks consisted of 

the preparation of a surveillance plan, insight into subcontractor safety operations, and 

audits of contractor safety operations to ensure that USA implemented all SSP safety 

requirements for ground operations. The SSP Safety Manager also attempted to 

subdelegate the same safety tasks for integrated logistics to the integrated logistics TMR; 

however, the integrated logistics TMR refused to accept the subdelegation. 

 10 The SFOC Contracting Officer delegated specific technical responsibilities, including surveillance 

responsibilities over USA to 13 TMR’s. The TMR’s are assigned to each major SSP component. The 

major components are SSP business management, SSP systems integration, safety and mission assurance, 

SSP management integration, avionics and software, flight crew operations, mission operations, Space 

Shuttle vehicle engineering, Space Shuttle upgrades, Space Station Office at Johnson, Solid Rocket Booster 

Project Office at the George C. Marshall Space Flight Center, and integrated logistics and ground 

operations at Kennedy. As a result of our audit, SSP management combined the safety responsibilities for 

both Kennedy operations under one TMR. 11 NASA Space Transportation System 07700, Volume 1, paragraph 3.4.1.3, “Space Shuttle Program

Requirements,” designates the SSP Safety Manager as being responsible for managing Space Shuttle Safety 

and Mission Assurance implementation and for oversight of all Safety and Mission Assurance activities in

support of the SSP. Paragraph 1 of the SFOC statement of work requires the contractor to follow the 

requirements of the NASA Space Transportation System 07700. 
Findings and Recommendations 

Finding A. Shuttle Safety Responsibilities at Kennedy 

Kennedy’s procedures to ensure that USA properly implemented SSP safety requirements 

for ground operations and integrated logistics contradicted procedures defined in the 

SFOC. Specifically, Kennedy performed surveillance and audits of USA’s safety 

operations rather than day-to-day management, review, and approval of USA’s work. 

This occurred because the SSP Safety Manager directed Kennedy to perform safety 

procedures that differed from the SFOC requirements. Implementing a level of oversight 

that contradicts that required by the SFOC could lead to lapses in safety oversight, 

increasing the risk of harm to personnel and damage to Space Shuttle hardware. 

SFOC Requirements Related to Shuttle Safety Oversight Responsibilities 

The SFOC requires that NASA provide day-to-day management of USA’s safety operations 

until that responsibility is transitioned (as agreed to by NASA) to USA, as documented in the 

SFOC statement of work, Transition Plan,12 and Management Plan.13 

The SFOC statement of work requires that: 

The contractor shall develop a plan, including schedule, that demonstrates

and measures the transition from the existing contractor/government

relationship and responsibilities to the contractor’s planned approach to

safety and mission assurance for this contract. 

The SFOC Transition Plan describes the nature of the responsibilities that are to be

transitioned from NASA to USA, stating, “NASA will move from an inspection role (review 

and approval) to one of insight (audit and surveillance).” 

In addition, the SFOC Management Plan, which is the most current document on SFOC 

management approaches, roles, and responsibilities, indicates that NASA should provide dayto-day management of USA’s safety process until NASA transitions that responsibility to 

USA. Paragraph 1.2.1 of the Management Plan defines the level of oversight required of 

NASA as follows: 

 12 The SFOC Transition Plan, Attachment J-A of the SFOC, describes USA’s proposed plan for assuming

the responsibilities documented in the SFOC statement of work. Specifically, Section 2.0 of the plan 

describes the generic approach that all USA organizations use to plan and execute transition of NASA tasks 

to USA. 13 Paragraph 1.1.1.1 of the SFOC requires USA to provide and maintain a management plan. The SFOC

Contracting Officer’s Technical Representative approved the Management Plan. Revision A of the 

Management Plan, dated February 2001, acknowledges that many operations have already transitioned 

from NASA to USA; however, safety was not one of the transitioned operations. 

2
NASA’s operations management role will shift from “oversight” defined as 

day-to-day management of work, to “insight,” defined as audit and 

surveillance of work to a level of detail that provides assurance of 

satisfactory work accomplishment. 

The SFOC Transition Plan states that the SSP safety responsibility will be transitioned to 

USA by October 1998. However, the SSP Safety Manager stated that USA was not 

capable of being fully responsible for safety and, therefore, did not transition safety 

oversight responsibilities to USA. Additionally, USA has not submitted an updated 

transition plan. As a result, the Transition Plan continues to define NASA’s oversight 

role as one of review and approval of USA’s safety operations. Similarly, the February 

2001 Management Plan does not acknowledge that responsibility for safety was 

transitioned to USA. 

In accordance with the SFOC safety provisions, NASA’s responsibilities for ensuring that

USA implements all SSP safety requirements should consist of day-to-day management, 

review, and approval of USA’s work. The SFOC Contracting Officer delegated the 

responsibility for safety oversight of USA to the SSP Safety Manager at Johnson who, in turn, 

subdelegated insight responsibility to the Kennedy TMR’s for ground operations and 

attempted to subdelegate insight responsibilities to the TMR for integrated logistics. 

Kennedy SSP Safety Procedures 

Kennedy’s procedures to ensure that USA properly implemented SSP safety requirements for 

ground operations and integrated logistics contradicted procedures defined in the SFOC. 

Kennedy performed surveillance and audits of USA’s safety operations rather than day-to-day 

management, review, and approval of USA’s work as defined in the SFOC. The Chief of the 

Kennedy Shuttle Safety Office, the office that provided the safety support to the TMR for 

ground operations,14 informed us that his office does not oversee day-to-day USA safety 

operations or provide direction for the implementation of NASA’s safety requirements as 

stated in the SFOC. Rather, the Kennedy Shuttle Safety Office gains insight into USA’s

safety operations through surveillance, audits, and the collection of metrics15 on the risks to 

safety as required by the SSP Safety Manager’s subdelegation. 

SSP Manager’s Direction for Safety Responsibilities at Kennedy 

The SFOC safety requirements and Kennedy’s safety procedures differed because the SSP 

Safety Manager defined oversight to mean that NASA is responsible for establishing the 

safety requirements and directing USA to perform those requirements. Therefore, the SSP 

Safety Manager directed the Kennedy TMR’s to perform surveillance and audits to ensure that 

USA was implementing NASA safety requirements satisfactorily. This direction contradicted 

the SFOC statement of work, Transition Plan, and Management Plan. Although the SSP 

 14 The TMR for ground operations is the Deputy Director of the Shuttle Processing Directorate at Kennedy. 15 The SFOC requires that USA maintain metrics, which are determined by risk assessments, Government 

mandatory inspections, and mishap investigation reports. 

3
Safety Manager’s definition of oversight differed from the SFOC definition, Johnson and 

Kennedy officials made no effort to ensure that the SFOC and the SSP Safety Manager’s 

practice for safety oversight were in agreement. 

Effects of Contradictions in Safety Responsibilities 

By using safety oversight procedures that contradicted SFOC requirements, NASA 

weakened the overall SSP safety management control environment,16 resulting in a 

potential lack of responsibility and accountability in the event of a serious mishap. 

Without strict adherence to contractual requirements, line safety personnel could be 

confused about their responsibilities, resulting in lapses in safety oversight. Further, the 

SFOC makes NASA fully accountable for harm to personnel and damage to SSP assets in 

the event of a serious mishap. 

Recommendation, Management’s Response, and Evaluation of 

Management’s Response

1. The Director, Lyndon B. Johnson Space Center, should direct the SFOC Contracting 

Officer and the SSP Safety Manager to ensure that NASA and USA safety personnel 

comply with the SFOC safety requirements or modify the SFOC, including the 

Management Plan and Transition Plan, to accurately reflect the actual safety practices

and responsibilities NASA and USA perform.

Management’s Response. Nonconcur. NASA stated that Agency policy, Center 

Directives, and SSP requirements establish safety responsibilities and processes; whereas 

the SFOC established the performance standards associated with implementing specific 

SSP tasks. Therefore, it is inappropriate for the Johnson Director to direct NASA safety 

personnel to perform tasks associated with the SFOC. However, to meet the intent of the 

recommendation, Kennedy and the SSP Office will verify that the appropriate Kennedy

organizations are complying with NASA oversight requirements. The complete text of 

management’s response is in Appendix F. 

Evaluation of Management’s Response. The SFOC, which references all NASA 

policy, Center Directives, and SSP requirements, is a binding agreement between USA 

and NASA and, as such, it should accurately reflect actual practices to be performed by 

both parties. Having a contract document that directly contradicts actual practices could 

result in a lack of responsibility and accountability in the event of a serious mishap. As 

stated in the report, without strict adherence to contractual requirements, line safety 

personnel could be confused about their responsibilities, resulting in lapses in safety 

oversight. Although NASA nonconcurred with the recommendation, management’s 

planned action to verify that the appropriate Kennedy organizations are complying with 

 16 The General Accounting Office’s, “Standards for Internal Controls in the Federal Government,” 

November 1999, define the control environment as the environment throughout an organization that sets a 

positive and supportive attitude toward internal control and conscientious management. Specifically, the 

standards require that appropriate authority, responsibility, and accountability be defined and delegated to 

accomplish the agency’s mission. 

4
NASA oversight requirements is responsive to the recommendation. As part of its 

assessment, management should ensure that the SFOC requirements and actual practices 

are in agreement. The recommendation is resolved, but will remain undispositioned and 

open for reporting purposes until corrective actions are completed. 

5
Finding B. Safety of Shuttle Integrated Logistics 

Kennedy had not ensured that USA implemented all safety requirements for the SSP 

integrated logistics function.17 Specifically, Kennedy performed no oversight of 

integrated logistics as required by the SFOC. This occurred because the TMR for 

integrated logistics at Kennedy18 refused to accept the subdelegated safety responsibilities 

because she did not feel qualified, and SSP officials did not take appropriate action to 

ensure that a qualified individual was accountable for integrated logistics safety at 

Kennedy. As a result, NASA had reduced assurance that personnel, space flight 

hardware, and other equipment were adequately protected in a high-risk area of the SSP. 

SFOC Requirements for Contractor Surveillance 

The SFOC allows the NASA Contracting Officer to appoint one or more TMR’s to monitor 

specified work areas. Under this authority, the Contracting Officer appointed a total of 13 

TMR’s and assigned specific contract responsibilities to each through a formal delegation 

letter. The delegation letter requires the TMR to: 

Establish . . . a surveillance plan that will ensure receipt of the quantity 

and kinds of supplies or services required by the Statement of Work of 

the contract. The surveillance plan shall include, but not be limited to, 

identification of how the contractor will be evaluated against the 

metrics identified in attachment J-1-B of the contract. 

One of the specific work areas was integrated logistics at Kennedy, which the SFOC 

Contracting Officer assigned to a TMR. Integrated logistics consists of repairs, 

maintenance, spare parts, warehousing for the Space Shuttle orbiters, and GSE. The SSP 

Safety Manager, through authorization by the SFOC Contracting Officer, subdelegates 

the responsibilities for surveillance and audit of USA’s safety operations at the Centers to 

the appropriate TMR’s by way of NASA Form 1430, “Letter of Contract Administration 

Delegation.” Acceptance of the delegation is documented by NASA Form 1431, “Letter 

of Acceptance of Contract Administration Delegation.” Appendix C lists the 

responsibilities specified in the subdelegation. 

Safety Reviews of Kennedy Integrated Logistics 

The TMR did not prepare and maintain an integrated logistics safety surveillance plan or

annual audit schedule and did not perform the required surveillance or audits of USA’s 

integrated logistics safety activities as specified in the SSP Safety Manager’s intended 

subdelegation. The Kennedy Shuttle Safety Office prepared a general Shuttle Safety and 

Mission Assurance Surveillance Plan; however, the plan did not cover any specific 

 17 As described in Finding A, there were discrepancies between the level of oversight required by the SFOC

and the safety insight that Kennedy performed. 18 The TMR for integrated logistics is the Director of the Logistics Division within Kennedy’s Shuttle 

Processing Directorate. 

6
integrated logistics operations. Similarly, the Kennedy Shuttle Safety Office prepared an 

annual Shuttle Safety and Mission Assurance audit schedule but had not planned or 

performed audits in the integrated logistics area. 

Integrated Logistics Safety Subdelegation 

The lack of safety surveillance and audits of USA’s safety processes in the integrated 

logistics area occurred because there was no NASA official in charge of subdelegated 

safety responsibilities in the area. Although the SSP Safety Manager subdelegated safety 

responsibilities to the integrated logistics TMR, she never accepted the subdelegation. 

The TMR informed us that she refused to accept the subdelegation because she was not 

qualified to evaluate USA’s safety procedures and, therefore, would not accept the 

responsibility. 

The SFOC Contracting Officer, SSP Safety Manager, and Kennedy Shuttle Processing 

officials acknowledged that the TMR for integrated logistics had not accepted the safety 

subdelegation. The SSP Safety Manager issued the subdelegation in May 1999 (more 

than 2 years prior to our audit), and neither the SSP nor Kennedy Shuttle Processing 

Directorate officials took actions to ensure that a qualified individual was accountable for 

integrated logistics safety at Kennedy. As a result of our audit, the SSP Safety Manager 

revised the letter of delegation, and the Kennedy Deputy Director for Shuttle Processing 

agreed to accept the subdelegated responsibilities.

Integrated Logistics Hazards 

The integrated logistics function covers critical Space Shuttle hardware such as the 

orbiter vehicles and GSE and includes repairs, manufacturing, transportation, and 

warehousing operations, which have a higher potential for injuries and mishaps. Prior to 

our audit, NASA performed no oversight or insight of USA’s Space Shuttle integrated 

logistics operations and, therefore, NASA had no assurance that personnel, space flight 

hardware, and other equipment were adequately protected in a high-risk area of the SSP. 

Recommendation, Management’s Response, and Evaluation of 

Management’s Response 

2. The Director, Lyndon B. Johnson Space Center, should direct the SSP Safety 

Manager to subdelegate to a qualified NASA official the responsibility to ensure that 

USA implements all NASA safety requirements for integrated logistics at Kennedy and 

to ensure that those subdelegated responsibilities are accepted and implemented. 

Management’s Response. Concur. The Shuttle Safety Manager subdelegated SFOC safety 

insight responsibilities for both ground operations and integrated logistics to the Kennedy 

Shuttle Processing Directorate who has accepted and implemented the subdelegation 

(see Appendix F). 

7
Evaluation of Management’s Response. On May 28, 2002, NASA provided us a copy of 

the signed NASA Form 1431, “Letter of Acceptance of Contract Administration Delegation.” 

We consider the action sufficient to disposition the recommendation, which will be closed for 

reporting purposes. 

8
Finding C. Shuttle Ground Support Equipment Safety Analyses 

USA improperly used critical GSE19 for critical Space Shuttle operations before the 

completion of required safety analyses20 and without adequate safety procedures to ensure the 

safe use of the GSE pending the completion of the analyses. The questioned GSE included 

monitors designed to alert personnel to an oxygen-deficient environment, cranes for hoisting 

critical solid rocket booster components, a ground coolant system that monitors the 

environment of the Space Shuttle crew compartment, transporters for moving the Space 

Shuttle to and from the launch pads, platforms for lifting personnel, and a fire extinguishing 

system. Improper GSE use occurred because of insufficient USA and NASA management 

control over USA’s System Assurance Analysis (SAA)21 process to ensure that USA 

implemented all NASA requirements for safety analyses. Using GSE for which all possible 

hazards had not been identified and controlled may have increased the safety risks to

personnel and Shuttle hardware. 

NASA Requirements for Safety Analyses 

NASA has several requirements22 governing the performance of GSE safety analyses. 

Those requirements generally state that USA should perform safety analyses to identify 

and control hazards associated with new GSE or hazards that may be introduced into the 

GSE through a modification. Sound safety practices require that personnel implement 

sufficient interim safety procedures (such as installing special safety devices or safety 

warnings) for the use of any GSE before completing a safety analysis. USA documents 

its safety analyses in the SAA. USA’s engineering community, including USA’s Safety 

and Reliability Engineering Division, Ground Systems Design Engineering Division, and 

Systems Engineering Division, review and approve the SAA’s. 

The TMR for ground operations was responsible (by subdelegation from the SSP Safety 

Manager) for the performance of surveillance and audit of USA’s operations to ensure 

that USA met all NASA requirements for safety analyses. The Kennedy Shuttle Safety 

Office supported the TMR by performing the surveillance and audits. 

 19 A GSE system is considered critical if loss of overall system function or improper performance of a 

system function could result in loss of life, loss of an orbiter vehicle, or damage to a vehicle system. An

operation is considered critical if significant hazards are present to personnel, space flight hardware, or 

space flight hardware systems. 20 The required analyses were (1) Hazard Analyses and (2) Failure Modes and Effects Analyses. 21 An SAA includes a system description, ground rules/assumptions, criticality assessment, Failure Modes 

and Effects Analysis/Critical Items List, and Hazard Analysis. Collectively, the analyses included in the

SAA are intended to identify the necessary actions to eliminate or control any failures or malfunctions of 

GSE that could independently or collectively present a hazard. 22 Requirements are in NASA Space Transportation System 22206, "Requirements for Preparation and 

Approval of Failure Modes and Effects Analysis and Critical Items List"; NASA Space Transportation 

System 5300.4 (1D-2), “Safety, Reliability, Maintainability, and Quality Provisions for the Space Shuttle 

Program”; Kennedy Program Directive 8710.1, “KSC/Safety, Reliability, Maintainability and Quality 

Assurance Programs”; and the SFOC Safety and Health Plan. 

9
Critical GSE Undergoing Analysis

USA’s Reliability Engineering Division provided us a list of the critical GSE systems

23 for 

which SAA’s were in process as of October 1, 2001. The list consisted of 101 GSE systems. 

From that population, we reviewed 11 (11 percent) critical GSE systems to determine whether 

USA used the GSE properly and safely in critical and noncritical operations. We found that 

USA used 6 (55 percent) of the 11 GSE systems, comprising 10 items of GSE, prior to 

completion of safety analyses and without interim safety procedures governing the use of the 

GSE before completion of the SAA. USA had completed SAA’s for the remaining five GSE 

systems we reviewed; however, the analyses should have been updated as a result of 

modifications to the equipment or a change in equipment use. A detailed description of our 

review is in Appendix D. 

SAA Management Controls 

The use of critical GSE prior to the completion of required SAA’s occurred because of 

insufficient USA and NASA management controls over the SAA process. Although USA 

had procedures regarding when and how to perform SAA’s, USA had not established 

procedures (such as implementing special safety guards or warnings) to ensure the safe use of

GSE in critical operations pending the completion of an SAA. Instead, USA relied on the 

institutional knowledge of the technicians and system engineers to ensure the safe use of the 

GSE. Kennedy Shuttle Safety Office personnel were familiar with the SAA process and 

stated that USA should have procedures to ensure the safe use of GSE in critical operations 

prior to completion of SAA’s. However, we found no evidence that the Kennedy Shuttle 

Safety Office reviewed USA’s procedures for using the GSE or reviewed the corresponding 

SAA’s that we sampled. 

Kennedy Shuttle Safety officials acknowledged the need for increased attention to USA’s 

processes for implementing requirements related to the approval and use of GSE in critical 

applications. As a result of our audit, the Shuttle Processing Directorate intends to review

USA’s processes for managing new and modified equipment. 

Effects of Using Ground Support Equipment Prior to Completion of an Analysis 

By allowing the use of critical GSE in critical operations prior to the completion of SAA’s,

NASA and USA lacked assurance that all possible hazards were adequately identified and

properly controlled. Without such assurance, the safety risks to personnel, critical items of

Space Shuttle hardware, and other equipment were potentially increased. The 10 GSE items 

in our sample consisted of 2 oxygen deficiency monitors, 2 overhead bridge cranes, a ground 

coolant system, 2 crawler transporters, 2 mobile manlift platforms, and a fire extinguishing 

system. 

USA’s Lead Reliability Engineer told us that USA’s use of the oxygen deficiency monitors 

was a problem and that USA would take immediate corrective action. However, he was 

 23 A GSE system can consist of one or several items of GSE. For example, the Space Shuttle crawler 

transporters are listed as one system but consist of two crawlers. 

10
confident that the other items of GSE were used safely, even though the use of the items was 

not supported by current SAA’s, interim safety procedures, or safety office approval. The 

risks associated with using the items of GSE in question are significant and warrant the 

implementation of interim safe operating procedures to ensure that the GSE is safe to use prior 

to the completion of SAA’s, as discussed below: 

Sensitive information and corresponding footnotes 24, 25 and 26omitted** 

 24 **Sensitive information omitted** 25 **Sensitive information omitted** 26 **Sensitive information omitted**

11
**Sensitive information and corresponding footnotes 27 and 28omitted** 

Conclusion 

Each item of questioned GSE is critical because failure of the system could be hazardous 

to personnel, space flight hardware, or other items of GSE. Using the GSE without 

identifying all potential hazards increases the risk of those hazards. Further, because we 

questioned the use of unanalyzed GSE based on only an 11-percent sample of 101 GSE 

items, the magnitude of the problem could be even greater. Until USA completes the 

SAA’s, it should have adequate interim safety procedures in place to ensure the safe use 

of each item of GSE. 

Recommendations, Management’s Response, and Evaluation of 

Management’s Response 

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

3. Direct the Kennedy Shuttle Processing Directorate to review USA’s processes 

for implementing SSP requirements related to the approval and use of GSE in critical 

applications. The assessment should include reviewing USA’s SAA’s to ensure GSE is 

used properly. 

 27 **Sensitive information omitted** 28 **Sensitive information omitted**

12
Management’s Response. Concur. NASA will complete an internal assessment of USA 

implementation of SSP requirements related to the approval and use of GSE in critical 

applications (see Appendix F). 

Evaluation of Management’s Response. Management’s planned action is responsive to the 

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

for reporting purposes until the corrective action is completed. 

4. Direct the Kennedy Shuttle Processing Directorate to review the 101 

critical GSE systems for which SAA’s are in process and either approve or suspend 

USA’s continued use of the systems pending completion of the SAA’s. 

Management’s Response. Partially concur. The report makes an erroneous conclusion 

that if an SAA is in process, then the GSE or GSE system cannot be used in operations. 

Management reviewed the 101 critical GSE systems for which SAA’s were in process 

and found that 57 of the SAA’s were for either systems that were in the design phase or 

modifications that had not yet been implemented, and 2 of the systems were not in use. 

Based on the same review, management also removed two systems from use until the 

appropriate analysis and precautions are in place. In conjunction with the corrective 

action associated with recommendation 3, NASA will finish the assessment of the 

remaining critical GSE systems for proper implementation of safety requirements (see 

Appendix F). 

Evaluation of Management’s Response. The OIG recognizes that, in certain circumstances 

and by implementing appropriate safety precautions, GSE systems can be used safely prior to 

completion of the SAA. However, as stated in the report, our review of a sample of 11 critical 

GSE systems undergoing analysis showed no evidence of appropriate safety precautions for 6 

(55 percent) of the systems, even though those systems were in routine use. According to the 

GSE documentation, the revised SAA’s were required because modifications to the systems or 

systems’ intended use affected safety. Accordingly, we believe interim safety precautions 

should have been in place to ensure the safe use of the GSE prior to completion of the 

analyses. As management found during its review of the 101 critical GSE systems, there was 

a lack of control over the safe use of modified GSE systems for which SAA’s were in 

progress. This was evidenced by NASA’s decision to remove two systems from service until 

the appropriate analyses and precautions are in place. Although NASA partially concurred 

with the recommendation, its planned action to review the remaining questioned GSE systems 

is responsive. The recommendation is resolved but will remain undispositioned and open for 

reporting purposes until the corrective action is completed. 

13
Finding D. Safety Procedures for Payload Installation and Removal 

USA did not have adequate evidence to show that it had performed several required safety 

procedures for the removal of a payload from an orbiter vehicle in Kennedy’s Orbiter

Processing Facility. This condition occurred because the Kennedy Shuttle Safety Office did 

not review USA’s procedures to ensure USA performed and documented all required payload 

installation and removal safety procedures. Nonperformance ofsafety procedures increases 

the risk of harm or damage to personnel, space flight hardware, and other equipment related to 

hazardous operations. 

SFOC Safety Requirements 

The SFOC statement of work, Section 1.3.1 states, “The contractor shall develop 

documented and auditable approaches to achieve safe program operations and assure 

flight safety.” USA documents its safety approaches at Kennedy in its Ground Safety 

Operating Procedures 5400 document.29 The purpose of Ground Safety Operating 

Procedures 5400 is to specify and establish safety policies and procedures required during 

operations and maintenance activities at USA-designated areas of Kennedy. Volume II 

of the document describes USA’s 77 Safety Operating Procedures (SFOP’s)30 that govern 

the safety procedures required in key operations USA performs at Kennedy under the 

SFOC. According to USA and Kennedy safety personnel, the specific safety procedures 

for each SSP operation should be documented in various work authorization documents31

(see Appendix E). 

The SFOC safety subdelegation requires the Kennedy Shuttle Safety Office to perform

surveillance and audits of USA’s safety activities to ensure safe operations at Kennedy’s 

Space Shuttle processing facilities. 

SFOP 33, “Payloads Installation/Removal in the Orbiter Processing Facility” 

We reviewed32 SFOP 33, “Payloads Installation/Removal in the Orbiter Processing Facility,” 

for a payload removal that occurred in May 2001. The payload removal operation was a 

hazardous operation because it involved hoisting and moving large pieces of space flight 

hardware up, over, and around personnel and the Space Shuttle orbiters. The photographs that 

follow show a similar operation that we observed: 

 29 Ground Safety Operating Procedures 5400 is incorporated into the SFOC by reference. 30 The 77 SFOP’s are the primary processes used in preparing the Space Shuttle for launch. They consist of 

such operations as mating the orbiter to the external tank and solid rocket boosters and transferring the 

vehicle to the launch pad. 31 Work authorization documents are the detailed instructions, including safety procedures, that direct

USA’s work and the work of its subcontractors in the performance of SFOC operations. 32 We selected an SFOP that was well documented, recently performed, and involved work relating to the 

Space Shuttle orbiters. USA safety officials agreed that SFOP 33 would be representative of the type of 

work performed by USA and the Kennedy Shuttle Safety office in support of the SFOC and that an audit 

trail of documented safety procedures could be easily followed. 

14
Payload lifting and removal operation33

The SFOP specifies the support, safety equipment, safety instructions, responsibilities, and 

emergency procedures to be followed during tasks and operations involved in payload 

installation and removal from the Space Shuttle orbiter vehicles while in the Orbiter 

Processing Facility. USA safety personnel told us that a review of the top-level work

authorization documents34 would illustrate and provide sufficient evidence of work performed 

in satisfaction of the SFOP and that most activities specified in the procedure would be easily 

traced to the actual work authorization documents that contained sign-offs and/or stamps by 

the individuals who performed or witnessed the work. We reviewed the work authorization 

documents and other supporting documentation pertaining to the removal and transportation 

of the May 2001 payload removal (International Space Station Multi-Purpose Logistics 

Module) from Orbiter Vehicle 105 and found no evidence that USA or NASA performed 

several required safety procedures. 

Evidence Of Required Safety Procedures 

We found no evidence that either USA or NASA had performed several required safety 

procedures for the May 2001 payload removal. Specifically, we determined the 

following: 

 33 **Detailed description of photograph omitted** 

34 USA stated that work authorization documents S0065.002-B01-R01 (S0065) and N52100-A01-R01

(N52100) are the top-level documents that control payload removal in the Orbiter Processing Facility. In

addition, we reviewed two lower-level Boeing subcontracting work authorization documents (L5050 and

L5051) that supported the operation.

15
• There was no evidence that USA performed some critical safety procedures 

required by SFOP 33. The procedures were to verify that (1) personnel were 

certified for tasks as required; (2) safety showers and eyewash fountains were 

operational; (3) all hoisting and handling equipment had current certification and 

preoperational checks had been performed; (4) fire detection, suppression, and 

alarm systems were operational; (5) tag lines35 were used to control the load; (6) 

operations would be immediately terminated if communications were lost and 

would not recommence until communications were restored; and (7) the crane 

ground controller had sole responsibility for communications with crane operators 

during crane operation. 

• USA documentation required by the SFOC was inadequate to show the NASA or 

USA Safety Office involvement required by SFOP 33 for some of the activities 

specified in the work authorization documents. The work authorization documents 

require USA safety office support, but do not clearly state or document what 

support was provided. Also, one of the top-level work authorization documents 

(N52100) states that hazardous operations cannot commence until a safety official 

has given concurrence, evidenced by that safety official’s signature. Although we 

identified USA safety personnel signatures within the work authorization 

documents, we could not associate the signatures with any specific activity. 

• The work authorization documents were inconsistent regarding essential personnel, 

that is, those whose presence was deemed critical during the operation. 

Specifically, the Operations Support Setup and the Post Operation Instructions 

sections of S0065 specify that NASA representatives, including safety office 

personnel, are essential personnel. In fact, the Operations Instruction section 

specifies that at least one NASA safety engineer is essential at Level 13,36 whereas 

N52100 states that a NASA safety representative is not essential at Level 13. None 

of the work authorization documents indicated whether the personnel considered 

essential during certain phases of the operation were, in fact, present. 

• Some specific safety procedures described in the work authorization documents were

not in SFOP 33, indicating that SFOP 33 may need updating. For example, one 

top-level work authorization document (S0065) states that during the pre-operation 

safety walkdown, safety representatives are to look for flammable or staticproducing materials in the control area. This procedure was not included in the 

SFOP. 

 35 Tag lines are ropes or wires used by ground personnel to guide the movement of the hoisted payload. 36 Level 13 is comprised of the highest level of access platforms surrounding the orbiter as it undergoes 

processing and checkout activities in the Orbiter Processing Facility. In addition to providing access to the 

orbiter, Level 13 is used for observation of activities. 

16
NASA Review of USA SFOP’s 

The Kennedy Shuttle Safety Office did not review USA’s operations to ensure that its

payload installation and removal safety procedures were properly followed and 

documented. The SFOC safety subdelegation requires the Kennedy Shuttle Safety Office 

to perform surveillance and audits of USA’s safety activities to ensure safe operations at 

Kennedy’s Space Shuttle processing facilities. The Chief of the Kennedy Shuttle Safety 

Office informed us that his office performed a proactive safety role by developing safety 

procedures for work authorization documents that USA must follow when performing 

SFOC operations, such as removing a payload from an orbiter. The Chief further stated 

that Kennedy Shuttle Safety Office personnel are present during high-risk operations, 

such as those involving moving large pieces of space flight hardware, and are available in 

case of an emergency. However, he stated that our audit approach of evaluating USA’s 

safety operations by reviewing one particular operation and ensuring that USA performed 

and documented all required safety steps was unique and that neither the NASA Shuttle 

Safety Office nor USA have performed reviews in that manner. 

In addition, the Chief of the Kennedy Shuttle Safety Office told us that Ground Safety 

Operating Procedures 5400 and the corresponding SFOP’s were originally NASA 

requirements. However, under performance-based contracting, USA assumed 

responsibility for the documents and, over the years, USA drifted away from properly 

performing and documenting all the procedures outlined in the SFOP’s. The Chief

agreed that all required safety steps must be performed and properly documented and that 

he would take action to ensure that USA initiated corrective action. 

Risks Involved in Payload Removal and Installation 

Our review of the operation and all associated documentation (SFOP 33 and the work 

authorization documents) disclosed no evidence that USA personnel performed some critical 

safety procedures, including (1) ensuring that all hoisting and handling equipment had current 

certifications and (2) performing all pre-operational checks. Further, the Kennedy Shuttle 

Safety Office did not ensure that USA performed and adequately documented its safety 

procedures. By not performing and documenting all required safety procedures and by not 

performing adequate oversight, USA and the Kennedy Shuttle Safety Office, respectively, 

increased the risk to personnel and space flight hardware. NASA and USA should ensure that 

all required safety procedures are performed for hazardous SSP operations and that complete 

documentation exists as evidence of those safety procedures. 

Recommendations, Management’s Response, and Evaluation of 

Management’s Response 

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

5. Require USA to ensure that all the safety procedures defined in SFOP 33 are 

properly implemented and documented for all future payload installation and removal 

procedures at Kennedy.

17
Management’s Response. Nonconcur. NASA did not concur because there is no 

requirement for all SFOP 33 requirements to be documented within the work

authorization documents. The Kennedy Shuttle Processing Directorate will verify that 

payload installation and removal procedures at Kennedy are accomplished in accordance 

with requirements (see Appendix F). 

Evaluation of Management’s Response. We are aware that there is no requirement for 

documenting all SFOP’s in the work authorization documents. However, the SFOC statement 

of work, Section 1.3.1 states, “The contractor shall develop documented and auditable 

approaches to achieve safe program operations and assure flight safety.” We interpreted this 

contract requirement to mean that there would be a clear traceability from USA’s written

safety procedures to evidence that the procedure was actually performed. USA safety officials 

agreed with that interpretation and told us that SFOP 33 would be representative of the type of 

work performed by USA and the Kennedy Shuttle Safety office in support of the SFOC and 

that evidence of all required safety procedures could be found in the associated work 

authorization documents. We could not find that evidence or determine whether NASA and 

USA performed specific safety procedures and, if they had performed the procedures, a record 

to document the work performed was not readily available. 

The intent of our recommendation was to ensure that USA provides a clear traceability of 

work performed to assure safe operations and SSP flight safety. Management’s planned 

action to verify that payload installation and removal operations are accomplished in 

accordance with NASA requirements meets the intent of our recommendation provided that 

there is documented evidence of the work performed. Therefore, the recommendation is 

resolved but will remain undispositioned and open for reporting purposes until the corrective 

action is completed.

6. Direct USA to determine whether SFOP 33 should be updated to include 

safety procedures that are specified in the work authorization documents but are not in 

the SFOP, and to update it as deemed necessary. 

Management’s Response. Partially concur. NASA stated that the SFOP requirements 

are itemized in the work authorization documents and that having additional items in the 

work authorization documents is acceptable and expected. The Kennedy Shuttle 

Processing Directorate and USA have reviewed the referenced work authorization 

documents and have determined that no update to SFOP 33 is required (see Appendix F). 

Evaluation of Management’s Response. Management’s action is responsive to the 

recommendation. We consider the action sufficient to disposition the recommendation, which 

will be closed for reporting purposes. 

7. Direct the Kennedy Shuttle Safety Office to include audits in its annual audit 

plan to ensure that USA performs all applicable SFOP requirements and properly 

documents the corresponding work authorization documents. 

18
Management’s Response. Concur. The Kennedy Shuttle Safety Office will ensure that 

SFOP requirement audits are incorporated into that office’s annual audit plans 

(see Appendix F). 

Evaluation of Management’s Response. NASA notified us on April 29, 2002, that the 

Kennedy Shuttle Safety Office revised its annual audit schedule to include audits to ensure 

that USA implements SFOP’s into USA work authorization documents. The audit is planned 

for August 2002. The recommendation is resolved but will remain undispositioned and open 

for reporting purposes until corrective actions are completed and we have verified that USA 

has properly documented that all SFOP requirements have been completed. 

19
Appendix A. Objectives, Scope, and Methodology 

Objectives

The overall objective of the audit was to evaluate United Space Alliance’s (USA’s) safety 

procedures for NASA's Space Flight Operations Contract (SFOC). The specific 

objectives related to this report were to determine whether: 

• safety responsibilities between USA and NASA were clearly defined and 

• NASA performed effective oversight of USA’s safety program. 

Scope and Methodology 

To accomplish our objectives, we did the following: 

• Discussed Space Shuttle Program safety with the NASA SFOC Contracting 

Officer, Administrative Contracting Officer, Contracting Officer’s Technical 

Representative and Safety and Mission Assurance Technical Management 

Representative, as well as safety personnel from the Lyndon B. Johnson Space 

Center (Johnson), John F. Kennedy Space Center (Kennedy), George C. Marshall 

Space Flight Center, and USA Safety and Mission Assurance offices. 

• Reviewed the SFOC Management Plan, Transition Plan, Safety and Heath Plan, 

and several NASA Space Transportation System documents. 

• Discussed with NASA and USA safety officials and staff from the USA 

Reliability Engineering Division the process for preparation of ground support 

equipment System Assurance Analyses. 

• Reviewed Agencywide, Kennedy specific, and USA policies and procedures for 

System Assurance Analyses of ground support equipment.

• Judgmentally selected and reviewed a sample of 11 items (11 percent) from the 

101 items of Kennedy ground support equipment for which System Assurance 

Analyses were in process as of October 1, 2001.

• Judgmentally selected and reviewed a USA safety procedure and associated work 

authorization documents governing the removal of a payload from a Space Shuttle 

orbiter vehicle in the Kennedy Orbiter Processing Facility.

• Observed the removal of an International Space Station Multi-Purpose Logistics 

Module from Orbiter Vehicle 103.

We did not assess the reliability of computer-processed data because we did not rely on it 

to achieve our audit objectives.

20
Appendix A 

Management Controls Reviewed 

We interviewed SFOC contracting, Space Shuttle Program, and USA safety personnel to 

identify applicable management controls such as contract administration and oversight 

responsibilities. We identified management control weaknesses as identified in the 

findings section of this report. 

Audit Field Work 

We performed audit field work from June 2001 through January 2002 at NASA 

Headquarters, Johnson, and Kennedy. We performed the audit in accordance with 

generally accepted government auditing standards. 

21
Appendix B. Summary of Prior Audit Coverage 

The NASA Office of Inspector General issued two prior audit reports related to USA 

safety practices. (See www.hq.nasa.gov/office/oig/hq/issuedaudits.html for copies.) 

“Controls Over the Use of Plastic Films, Foams, and Adhesive Tapes In and Around 

the Space Shuttle Orbiter Vehicles,” Report Number IG-01-034, August 31, 2001. 

John F. Kennedy Space Center (Kennedy) management acknowledged the safety risks of 

not properly controlling the use of plastic films, foams, and adhesive tapes (PFA’s) in 

NASA facilities and requires all such materials to be evaluated for flammability 

resistance, electrostatic discharge rate, and hypergolic compatibility37 characteristics. 

However, in and around the orbiter vehicles and other segments of the Space Shuttle, 

United Space Alliance (USA) routinely used PFA’s for which those characteristics were 

unknown. Neither the USA Safety Office nor the Kennedy Shuttle Safety Office had 

approved the materials for use. Further, USA’s procedures for the safe handling and use 

of PFA’s in and around the orbiter vehicles were not effective. 

The lack of control over the use of PFA’s created a potential safety hazard to personnel, 

the orbiter vehicles, and other flight hardware and equipment. We recommended that 

Kennedy (1) clarify procedures for approving the use of unapproved PFA’s, (2) request 

USA to reestablish its PFA’s testing requirements, (3) direct the Kennedy Shuttle Safety 

Office to be more actively involved in the safe use of PFA’s, (4) develop a centralized list 

of PFA’s approved for use in and around the Space Shuttle orbiter vehicles, and (5) direct 

the Kennedy Shuttle Safety Office to perform assessments on the control and use of

PFA’s found in Kennedy Space Shuttle processing facilities. Kennedy concurred with 

one recommendation, partially concurred with the remaining four, and has completed or 

planned appropriate corrective actions. 

“Space Shuttle Program Management Safety Observations,” Report Number 

IG-01-017, March 23, 2001. We evaluated NASA’s oversight of USA’s safety program. 

We identified several weaknesses pertaining to NASA's management control structure for 

providing oversight of USA’s safety operations under the Space Flight Operations 

Contract. Specifically, we found the following: 

• the Lyndon B. Johnson Space Center (Johnson) Safety, Reliability, and Quality 

Assurance Office was not providing the required support to the Manager, Space 

Shuttle Program Safety and Mission Assurance for oversight of USA’s safety 

activities; 

 37 Kennedy Handbook 1710.2, references the Kennedy Materials Sciences Division Intranet, which also

includes foams as materials that must 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. 

Electrostatic discharge rate – the material cannot hold a charge of more than 350 volts, 5 seconds after

termination of the initial charge. 

Hypergolic compatibility – the material should not have an extreme reaction such as discoloration or

temperature increase when exposed to hypergols (rocket fuel). 

22
Appendix B 

• NASA’s contractor surveillance plans did not address all contract requirements 

for safety;

• USA had not updated its Management Plan commensurate with the changes to the 

contract; and 

• USA could improve its reporting to NASA of close calls and mishaps. 

We recommended that Johnson ensure that (1) surveillance plans address all contract 

requirements for safety, (2) USA’s Space Flight Operations Contract Management Plan is 

kept current, and (3) USA promptly and accurately reports all required close call and 

mishap information to NASA’s reporting system. Johnson did not agree with all of the 

findings, but concurred with the recommendations. NASA implemented corrective 

actions to improve the overall management of safety for the Space Shuttle Program. 

23
Appendix C. Safety Responsibilities Subdelegated to the 

Integrated Logistics Technical Management Representative 

The Space Flight Operations Contract Contracting Officer’s Letter of Contract 

Administration Delegation subdelegated the following duties to the Technical 

Management Representative for integrated logistics at the John F. Kennedy Space Center: 

• Perform surveillance and evaluation of contractor and associated 

subcontractor/supplier activities associated with risk management and safety, 

reliability, maintainability, and quality assurance as defined in the statement of work 

or program requirements. 

• Gain real-time insight into activities at selected subcontractors. If delegation to other 

organizations is necessary, a strong framework of teamwork and regular 

communication should be developed and maintained. 

• Manage the resources provided to perform the obligations of this delegation. 

• Perform oversight of authorized subdelegated activities. 

• Provide Safety and Mission Assurance evaluation and technical assessment of 

engineering change requests. 

• Evaluate contract deliverable products for compliance and acceptability. 

• Resolve Safety and Mission Assurance technical issues in conjunction with United 

Space Alliance managers as required to fully facilitate United Space Alliance 

performance. 

• Prepare and maintain a Safety, Reliability, and Quality Assurance surveillance plan. 

This plan will outline the surveillance activity and information to be provided in 

support of the Safety and Mission Assurance Technical Management Representative. 

• Recommend to the Space Shuttle Program Safety Manager any desired changes in 

contract scope and/or technical provisions with justification. 

• Provide immediate notice of significant program problems or issues to the Space 

Shuttle Program Safety Manager. 

• Provide performance evaluation with substantiated metrics to the Space Shuttle 

Program Safety Manager. 

• Prepare and submit an annual audit schedule to the Space Shuttle Program Safety 

Manager. 

24
** Details of sample review information omitted** 

25
** Details of sample review information omitted**

26
Appendix E. Audit Trail of United Space Alliance 

Safety Procedures 

This document

supplements Kennedy

Handbook 1710.2

and establishes safety

policies and procedures

for operations and

maintenance activities

at USA*-run areas of

Kennedy Space Center.

The contract includes

Section J-01 Paragraph

1.3 - Safety Mission

Assurance, and

Product Assurance, and

references Kennedy

Handbook 1710.2,

"Kennedy Safety

Practices Handbook."

The procedures are

specified in USA's*

Ground Safety

Operating

Procedures,

5400, Revision D,

dated 11/15/00,

including Safety

Operating Procedure

33 -"Payloads

Installation/Removal

in the Orbiter

Processing Facility"

(discussed in

Finding D of this

report).

The documents direct

USA's* performance

of authorized tasks,

including safety

procedures, for a

given operation. Once

USA has completed

the operation, the

documents comprise

the record of work

performed.

USA* performs the

safety procedures

during a given

operation as specified

in the work

authorization

documents. The

procedures include

obtaining NASA

Safety Office

concurrence,

performing safety

inspections, and

ensuring personnel

are properly trained

and equipment is fit

for use prior to the

start of the operation.

Ground

Safety Operating

Procedures 5400

Space Flight

erations

Contract

77 USA* Safety

Operating

Procedures

Work

Authorization

Documents

Actual Safety

Procedures

* United Space Alliance

27
Appendix F. Management’s Response 

28
Appendix F

29
Appendix F

30
Appendix F

**USA’s 

process

information 

omitted** 

31
Appendix F

32
Appendix G. Report Distribution 

National Aeronautics and Space Administration (NASA) Headquarters 

HQ/A/Administrator 

HQ/AI/Associate Deputy Administrator 

HQ/AA/Chief of Staff 

HQ/AB/Associate Deputy Administrator 

HQ/B/Acting Chief Financial Officer

HQ/B/Comptroller 

HQ/BF/Director, Financial Management Division 

HQ/G/Acting General Counsel 

HQ/H/Assistant Administrator for Procurement 

HQ/HK/Director, Contract Management Division 

HQ/HS/Director, Program Operations Division 

HQ/J/Assistant Administrator for Management Systems 

HQ/JM/Director, Management Assessment Division 

HQ/L/Assistant Administrator for Legislative Affairs 

HQ/M/Acting Associate Administrator for Space Flight 

HQ/Q/Associate Administrator for Safety and Mission Assurance 

HQ/QS/Director, Safety and Risk Management Division 

NASA Advisory Officials 

Chair, NASA Aerospace Safety Advisory Panel

NASA Centers 

ARC/D/Director, Ames Research Center 

DFRC/X/Director, Dryden Flight Research Center 

GRC/0100/Director, John H. Glenn Research Center at Lewis Field 

GSFC/100/Director, Goddard Space Flight Center 

JPL/1000/Director, Jet Propulsion Laboratory 

JSC/AA/Director, Lyndon B. Johnson Space Center 

KSC/AA/Director, John F. Kennedy Space Center 

KSC/CC/Chief Counsel, John F. Kennedy Space Center 

LaRC/106/Director, Langley Research Center 

MSFC/DA01/Director, George C. Marshall Space Flight Center 

SSC/AA00/Director, John C. Stennis Space Center 

33
Appendix G 

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, Office 

 of Management and Budget 

Director, Acquisition and Sourcing Management Team, General Accounting Office 

Senior Professional Staff Member, 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 Efficiency, Financial Management, and 

 Intergovernmental Relations 

House Subcommittee on Technology and Procurement Policy 

House Committee on Science 

House Subcommittee on Space and Aeronautics

Congressional Member 

Honorable Pete Sessions, U.S. House of Representatives 

34
NASA Assistant Inspector General for Audits 

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