IG-01-034

AUDIT

REPORT CONTROLS OVER THE USE OF PLASTIC

FILMS, FOAMS, AND ADHESIVE

TAPES IN AND AROUND THE SPACE SHUTTLE

ORBITER VEHICLES

August 31, 2001

National Aeronautics and

Space Administration

OFFICE OF INSPECTOR GENERAL
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Acronyms

ESD Electrostatic Discharge

GSOP Ground Safety Operating Procedures

M&P Materials and Processes

MAPTIS Materials and Processes Technical Information System

NSTS NASA Space Transportation System

OIG Office of Inspector General

PFA Plastic Film, Foam, and Adhesive Tape

SFOC Space Flight Operations Contract

USA United Space Alliance
W August 31, 2001

TO: A/Administrator

FROM: W/Inspector General

SUBJECT: INFORMATION: Controls Over the Use of Plastic Films, Foams, and Adhesive

Tapes In and Around the Space Shuttle Orbiter Vehicles

Report Number IG-01-034

The NASA Office of Inspector General (OIG) is performing an audit of the United Space

Alliance’s (USA’s) safety procedures under NASA’s Space Flight Operations Contract (SFOC).1

As part of the audit, we reviewed USA’s controls over the use of plastic films, foams, and adhesive

tapes (PFA’s) used in and around2 the orbiter vehicles and other segments of the Space Shuttle

such as the solid rocket boosters and main engines. As previously reported to you in Safety Alert

01-01, dated May 22, 2001, we found that USA was routinely using in and around the Space

Shuttle orbiter vehicles, PFA’s that had no record of being tested to ensure that the PFA’s met

NASA standards for flammability resistance, electrostatic discharge (ESD) rate, or compatibility

with rocket fuel. In addition, neither the John F. Kennedy Space Center (Kennedy) nor USA

safety personnel had approved the use of these materials, thereby creating a potential safety hazard

to personnel, the orbiter vehicles, and other flight hardware and equipment.

 

1

 NASA awarded the SFOC to USA of Houston, Texas, on September 26, 1996. USA is a joint venture of The

Boeing Company and Lockheed Martin to conduct the SFOC and is the prime contractor for NASA’s Space

Shuttle Program. USA performs work for SFOC under contract number NAS9-20000. The total contract cost plus

fee is estimated at $8.6 billion. The contract is a cost-plus-incentive-fee/award-fee type contract and has a

period-of-performance of October 1, 1996, through September 30, 2002. The contract includes two, 2-year option

periods, which potentially extend the period-of-performance through September 30, 2006.

2

 Revision A of NASA Space Transportation System 08242, “Limitations for Non-flight Materials and Equipment

Used In and Around the Space Shuttle Orbiter Vehicles,” (NSTS 08242) defines “in and around” as “in contact

with the orbiter's exterior surfaces or within approximately three feet of the orbiter's exterior mold line.” The SFOC

requires USA to conform to the NSTS 07700 series of documentation. NSTS 07700, "Space Shuttle Program

Requirements and Description," Volume V, references NSTS 08242 and states that a detailed materials list shall

be provided for all materials approved for use in and around the orbiter vehicle during ground operations.
2

We have addressed safety involving NASA contractors, including the control of PFA’s at

Kennedy’s payload processing facilities, in four prior audit reports.3 A synopsis of those reports is

in Appendix B.

Background

USA’s Space Shuttle processing activities at Kennedy occur in several facilities. In each of those

facilities, USA uses various PFA’s to protect surfaces of the orbiter vehicles and other segments of

the Space Shuttle. More specifically, USA covers sensitive electrical components with plastic film

secured with adhesive tape to prevent contamination. USA also uses foam padding inside

compartments of the orbiter vehicles to protect flexible hoses and cables from damage by

technicians. The same foam covers the wings of the orbiter vehicle to prevent damage during

processing.

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

plastic films, foams, and adhesive tapes pass acceptance criteria for flammability resistance, ESD

rate, and hypergolic compatibility.4 Kennedy and USA management have acknowledged the risks

of using PFA’s around Space Shuttle payloads and flight hardware. Such risks include fire ignition

from ESD sensitive materials and fire propagation through materials that do not meet flammability

standards. Since 1995, several fires involving PFA’s that did not meet NASA standards have

occurred in Kennedy facilities that house the orbiter vehicles and other hardware and equipment

(including an incident as recently as April 2001), resulting in significant property damage. Because

of those risks, NASA and USA have developed specific policies and procedures regarding the use

and control of PFA’s around space flight hardware.

Recommendations

We recommended that management improve the controls over the use of PFA’s in and around the

orbiter vehicles by developing one centralized list of PFA’s approved for use in and around the

orbiters, clarifying procedures for using materials not on the approved

 

3

 We issued reports No. IG-01-017, “Space Shuttle Program Management Safety Observations,”

March 23, 2001; No. IG-00-035, “Contract Safety Requirements at Kennedy Space Center and Marshall Space

Flight Center,” June 5, 2000; No. IG-00-028, “Safety Concerns with Kennedy Space Center’s Payload Ground

Operations,” March 30, 2000; and No. IG-99-047, “Safety Considerations at Goddard Space Flight Center,”

September 22, 1999.

4

 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.

ESD – 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).
3

list, and requiring personnel from the Kennedy Shuttle Processing Directorate's, Shuttle Safety and

Mission Assurance Division (Kennedy Shuttle Safety Office)to be more involved in the control and

use of PFA’s. We also recommended that management review a group of questioned PFA’s listed

in Appendix E of our report to ensure that the materials are being used safely. These

recommendations will help ensure that NASA knows the flammability, ESD, and hypergolic

compatibility characteristics for the PFA’s used in and around the orbiters and exercises proper

safety precautions based on those characteristics. These actions will help to reduce the risk of harm

to personnel and damage to the orbiter vehicles and other space flight hardware and equipment.

Management Response and OIG Evaluation

Kennedy partially concurred with all the recommendations, but we are concerned that the proposed

actions are responsive to only three of the five recommendations.5 Management responded that the

administration and documentation of the control and use of PFA’s needs improvement. Kennedy

asserted that all PFA’s used in and around the orbiter vehicles were used safely. Kennedy has

established an inter-Center team to review and improve requirements, policies, and processes

related to the use of PFA’s at Kennedy. Kennedy reviewed the PFA’s listed in Appendix E of our

report and asserted that all of those materials were used properly.

Kennedy did not provide specific corrective actions regarding how the Kennedy Shuttle Safety

Office will review all proposed USA Ground Safety Operating Procedure (GSOP) changes prior to

implementation as required by the SFOC, determine whether potential hazards are present in

operations, and approve and allow the use of materials that have failed required tests or have not

been tested. We have asked management to provide specific corrective actions and implementation

dates.

Although management concluded that it used all of the materials safely, that was not the case during

our audit field work. When we initially presented our audit results, management did not know

whether USA used the materials safely but stated that it would perform further research. More than

4 months after receiving our results, Kennedy concluded that USA used the materials safely even

though Kennedy was never able to present evidence of materials testing results from any NASA

Center or test facility. In our opinion, management should know at all times whether materials in or

around the orbiter vehicles are used in a safe manner.

 

5

 Management asserted that appropriate corrective action was taken in response to an official mishap report

attributing a 1995 fire in Kennedy’s Orbiter Processing Facility to improper use of PFA’s. However, since 1995,

at least two additional mishaps involving PFA’s have occurred in Kennedy facilities that house the Space

Shuttle orbiters and other hardware and equipment. In August 1998, a fire in USA's Kennedy Logistics Support

Facility started when a spark ignited gases in a plastic bag that held lithium batteries. In April 2001, vapors from

a bottle containing a waterproofing agent ignited in the Orbiter Processing Facility during the use of materials

that had a high potential for ESD. Additional corrective actions are warranted to ensure proper control of PFA’s.
4

Management also commented extensively on our findings (see Appendix F). We respond to those

comments in Appendix G of the report.

Details on the status of the recommendations are in the report’s recommendation section.

[original signed by]

Roberta L. Gross

Enclosure

Final Report on Audit of Controls Over the Use of Plastic Films, Foams, and Adhesive Tapes In

and Around the Space Shuttle Orbiter Vehicles
FINAL REPORT

AUDIT OF CONTROLS OVER THE USE OF PLASTIC FILMS,

FOAMS, AND ADHESIVE TAPES IN AND AROUND THE SPACE

SHUTTLE ORBITER VEHICLES
W August 31, 2001

TO: M/Associate Administrator for Space Flight

Q/Associate Administrator for Safety and Mission Assurance

AA/Director, John F. Kennedy Space Center

FROM: W/Acting Assistant Inspector General for Audits

SUBJECT: Final Report on Audit of Controls Over the Use of Plastic Films, Foams, and

Adhesive Tapes In and Around the Space Shuttle Orbiter Vehicles

Assignment Number A-00-041-01

Report Number IG-01-034

Enclosed please find the subject final report. Our evaluation of your response has been

incorporated into the body of the report and is included in its entirety in Appendix F. We consider

management's proposed corrective actions responsive for recommendations 1, 4, and 5. We

request that management provide additional comments on recommendations 2 and 3 by October

30, 2001. The additional comments should provide the specific corrective actions and

implementation dates in relation to how the Kennedy Shuttle Safety Office will (1) review all

proposed Ground Safety Operating Procedure (GSOP) changes prior to implementation as

required by the Space Flight Operations Contract (SFOC), (2) determine whether potential hazards

are present in operations, and (3) review and approve Material Use Permits or variances that allow

the use of materials that have failed required tests or have not been tested. The recommendations

will remain open for reporting purposes until corrective actions are completed. Please notify us

when action has been completed on the recommendations, including the extent of testing performed

to ensure corrective actions are effective. The final report distribution is in Appendix H.

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

report, please contact Mr. Kevin J. Carson, Deputy Assistant Inspector General for Audits, at

(301) 286-0498, or Mr. Karl Allen, Audit Program Manager, at

(202) 358-2595.

[original signed by]

Alan J. Lamoreaux

Enclosure
2

cc:

AI/Associate Deputy Administrator

B/Acting Chief Financial Officer

B/Comptroller

BF/Director, Financial Management Division

G/General Counsel

H/Associate Administrator for Procurement

JM/ Director, Management Assessment Division

QS/Director, Safety and Risk Management Division

AA/Acting Director, Lyndon B. Johnson Space Center
NASA Office of Inspector General

IG-01-034 August 31, 2001

 A-00-041-01

Controls Over the Use of Plastics Films,

Foams, and Adhesive Tapes In and

Around the Space Shuttle Orbiter Vehicles

Introduction

The OIG is performing an audit of USA’s Safety Procedures under NASA’s SFOC. USA is

responsible for the day-to-day operation and management of the U.S. Space Shuttle fleet. USA's

work affects the safety of NASA's astronauts, the Space Shuttle orbiters and other flight hardware,

personnel, and equipment. In conducting our audit, we reviewed USA’s controls over the use of

PFA’s in and around the orbiter vehicles and other segments of the Space Shuttle such as the solid

rocket boosters and main engines. We identified several weaknesses with the control of PFA’s and

are bringing these observations to management’s attention as we continue with our overall audit of

USA’s safety program.

Our overall audit objective is to evaluate USA safety procedures for NASA's SFOC. The specific

objective related to this report was to determine whether Kennedy properly controlled potentially

unsafe materials used in contract performance. Appendix A contains further details on the audit

objectives, scope, and methodology.

Results in Brief

Kennedy management has acknowledged the safety risks of not properly controlling the use of

PFA’s in NASA facilities and requires all such materials to be evaluated for flammability resistance,

ESD rate, and hypergolic compatibility characteristics. However, USA is routinely using in and

around the orbiter vehicles and other segments of the Space Shuttle PFA’s for which those

characteristics are not known. Neither the USA Safety Office nor the Kennedy Shuttle Safety

Office have approved these 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 in that USA (1) allowed a

Materials and Processes (M&P) engineer, rather than a safety professional, to make key safety

decisions regarding the use and testing of PFA’s; (2) changed its procedures concerning PFA’s

rather than comply with established testing and safety requirements; and (3) continued to use
2

materials that had contributed years earlier to a fire in the Kennedy Orbiter Processing Facility. 6

This lack of control over the use of PFA’s creates a potential safety hazard to personnel, the orbiter

vehicles, and other flight hardware and equipment.

Background

USA’s specific responsibilities include Space Shuttle modification, testing, checkout, launch and

landing activities at Kennedy, and flight operations at the Lyndon B. Johnson Space Center

(Johnson). USA’s Space Shuttle processing activities at Kennedy occur in several facilities,

including the (1) Vehicle Assembly Building;7 (2) three high bays of the Orbiter Processing Facility;

(3) Hypergolic Maintenance Facility;8 and (4) Rotation, Processing, and Surge Facility.9 In each of

these facilities, USA uses various PFA’s to protect surfaces of the orbiter vehicles and other

segments of the Space Shuttle.

The Kennedy Directors of Logistics Operations and Space Station and Shuttle Payloads recognized

the risks associated with using PFA’s in a June 1999 memorandum. The memorandum directed

personnel to improve safety procedures in two Kennedy processing facilities and emphasized the

need to properly control PFA usage as follows:

. . . it is important that the Materials and Processes (M&P) engineers control

the use of PFA’s and solvents in [the Operations and Checkout Building

and the Space Station Processing Facility]. . . . Compliance with the rules for

the use of materials that meet the requirements for flammability resistance,

electrostatic discharge, odor, offgassing, breakthrough resistance, and fluid

compatibility is mandatory to ensure safety, contamination control, and

mission success.

Control of PFA’s In and Around Space Shuttle Orbiter Vehicles

We identified PFA’s that are either in use or approved for use in and around the orbiters for which

USA has not properly identified the flammability resistance, ESD rate, and hypergolic compatibility

characteristics. USA did not have any of the PFA’s tested for those characteristics as required, and

Kennedy and USA safety professionals have not approved the PFA’s for use. This condition

exists because of (1) inadequate USA procedures for ensuring the testing and safe use of PFA’s,

(2) inadequate oversight by the Kennedy Shuttle Safety Office, and (3) incomplete material

 

6

 The Orbiter Processing Facility consists of three high bays, two low bays, and administrative space where USA

conducts post-landing orbiter vehicle inspections, testing, and refurbishment and installation and checkout of

the payload for the next mission.

7

 USA uses the Vehicle Assembly Building for (1) integration and stacking of the Space Shuttle vehicle, (2)

external tank checkout and storage, (3) contingency storage, (4) payload canister operations, and (5) solid rocket

booster handling.

8

 The Hypergolic Maintenance Facility consists of three buildings and all facilities required for USA to process

and store the hypergolic-fueled modules for the orbiter's reaction control system, orbital maneuvering system,

and auxiliary power units.

9

 USA uses this facility to isolate hazardous operations associated with solid rocket motor rotation and

processing capabilities and to conduct solid rocket motor receiving, rotation, and inspection.
3

approval and testing records. As a result, materials USA is using in or near the orbiter vehicles may

not meet NASA standards for flammability resistance, ESD rate, and hypergolic compatibility. This

situation creates a potential fire hazard and a safety risk to personnel, the orbiter vehicles, and other

flight hardware and equipment.

Requirements for Safe Use of PFA’s

The SFOC establishes the responsibilities for ensuring safe operations at Kennedy’s Space Shuttle

processing facilities as follows:

Safety Responsibilities at Kennedy’s Space Shuttle Processing Facilities

Organization Safety Responsibilities as Defined by the SFOC

USA

Develop and implement (1) an approach in which ground

operations and maintenance activities are assessed for hazards and

(2) a process in which NASA and other noncontractor personnel

and property are protected from injury or harm as a result of

exposure to those hazards.

NASA (Kennedy

Shuttle Safety

Office)

Perform surveillance, audits, and technical insight of contractor

safety and mission assurance activities; prepare and maintain a

ground operations safety surveillance plan; and review and

approve variance requests.

Numerous NASA-wide and Kennedy-specific requirements address the testing and control of

PFA’s and other materials. Appendix C provides details on these requirements.10 NASA and

Kennedy policies generally require that all PFA’s used near the orbiter vehicles be tested and

evaluated for NASA’s standards for flammability resistance, ESD rate, and hypergolic compatibility

characteristics. Use of the PFA’s must then be controlled based on those characteristics. Materials

that meet NASA standards are placed on approved lists.11 Materials that do not meet those

 

10 Attachment J-11 to the SFOC refers to applicable NASA policies and procedures. Specifically, the SFOC

incorporates, by reference, NASA-STD-6001 and Kennedy Handbook 1710.2. Appendix C of this report contains

additional requirements regarding PFA testing and control. These additional requirements are also incorporated,

by reference, into the SFOC contract.

11 Several sources identify the PFA's approved for use in and around the Space Shuttle orbiter vehicles: (1)

Appendix C of NSTS 08242, "Limitations for Non-flight Materials and Equipment Used In and Around the Space

Shuttle Orbiter Vehicles"; (2) Appendix I of USA’s GSOP 5400; (3) the Kennedy Materials Science Division's

Intranet; and (4) the George C. Marshall Space Flight Center’s (Marshall) online Materials and Processes

Technical Information System (MAPTIS), which contains test data for PFA’s tested at other NASA locations

such as Marshall or NASA’s White Sands Test Facility.
4

standards can be used only after obtaining a Materials/Equipment Usage Permit (Material Use

Permit)12 or a safety variance,13 both of which require USA and Kennedy safety office approval.

Based on the safety responsibilities as described in the SFOC and NASA and Kennedy policies on

the testing and control of PFA’s, the process flow for the safe use of PFA’s in and around the

Space Shuttle orbiter vehicles is depicted in Figure 1.

Figure 1. Process flow for the use of PFA’s In and Around the Space Shuttle Orbiter Vehicles.

PFA’s With Unknown Flammability, ESD, and Hypergolic Compatibility Characteristics

Through our observations14 and review of the lists of materials approved for use in and around the

orbiters, we identified 3015 PFA’s that were either in use or approved by

 

12 A Material Use Permit is a standard document that allows USA Task Engineers to use a certain type of

material, on a temporary or permanent basis, subject to the restrictions described in the document.

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

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

14 From July through October 2000, we toured six of the nine Kennedy facilities USA used for Space Shuttle

processing activities: the Vehicle Assembly Building; Hypergolic Maintenance Facility; Rotation, Processing,

and Surge Facility; and high bays 1, 2, and 3 of the Obiter Processing Facility.

15 The Kennedy Materials Science Lab could not provide testing data for Mystik 7000 tape (shown in Figure 2).

The Lab tested the Mystik 7000 tape in 1995 after a fire occurred in the Orbiter Processing Facility. The Kennedy

mishap file stated that the material failed ESD tests and, along with ACLAR plastic film, was a contributing factor

to the fire. Although we listed Mystik 7000 tape in Appendix E, we did not include it in our count of 30 PFA’s.

Propose use of

PFA to USA M&P

Specialist

Use material in

accordance with the

approved variance

USA Task Engineer

Kennedy Materials &

Sciences Lab

Test the PFA and

identify the 

flammability, ESD,

and hypergolic

compatibility 

characteristics.

USA Safety Office

-Identify and assess risks based

 on materials characteristics.

-Develop safe usage procedures

 based on identified risks

-Prepare variance that includes

the risks and safe usage procedures

Safety variance

(or Material Use 

Permit) request

Kennedy Shuttle Safety Office

Review and approve variance

request

Approved

safety variance

1

1

Perform Insight/

Surveillance

into USA safety

activities

If the material

meets NASA

standards, it is

placed on an

approved list.
5

NASA or USA for general use in and around the orbiter vehicles16 even though USA had no record

of test data and flammability, ESD rate, and hypergolic compatibility characteristics. We discussed

each of the 30 PFA’s with safety, M&P, and Space Shuttle program personnel from both USA and

Kennedy and reviewed available testing records and determined that:

• The Kennedy Materials Science Lab17 had not tested the 30 PFA’s for flammability, ESD rate,

and hypergolic compatibility.

• Marshall's online Materials and Processes Technical Information System (MAPTIS) contained

no evidence to support that 16 (53 percent) of the PFA’s had been tested for flammability

resistance, ESD rate, or hypergolic compatibility at any other NASA location. The test results

in MAPTIS for the remaining 14 PFA’s did not state whether the materials had passed or failed

required tests.

• Neither USA nor Kennedy had any record of Kennedy or USA safety office review and

approval for 29 of the 30 materials.

Figure 2 shows an example of the use of these materials.

 

16 During our tours of the six Space Shuttle processing facilities, we observed technicians using various PFA’s in

and around the orbiter vehicles and other components of the Space Shuttle and large quantities of PFA’s stored

in these facilities for USA’s future use. The PFA’s we observed in use were: (1) plastic films covering sensitive

flight hardware components to prevent contamination; (2) adhesive tapes securing plastic films to items of flight

hardware; and (3) polyvinyl foam insulating and protecting cables, work stands, and surfaces of the orbiter

vehicles, such as the wings. Appendix D of this report shows examples of such usage. NASA approved 24 of

the PFA’s by including them in Appendix C of NSTS 08242. Through the Material Use Permit process, Kennedy

and USA M&P personnel approved four of the PFA’s. We observed the remaining two materials, Armalon

fabric (shown in Figure 2) and RE22 tape (shown in Figure D-3 in Appendix D), affixed to the outer surfaces of

Orbiter Vehicle-105.

17 The Kennedy Materials Sciences Lab, a branch of the Materials Sciences Division, is identified by NSTS 08242

as the organization responsible for materials testing at Kennedy.
6

Figure

2.

Armalon fabric is adhered to outer tile of Orbiter Vehicle-105 (Endeavor) with Mystik 7000 tape. We

took this photograph in the Orbiter Processing Facility on October 17, 2000. A USA engineer

specialist identified these materials as Armalon fabric and Mystik 7000 tape.

Neither the Armalon fabric nor the Mystik 7000 tape shown in Figure 2 are on the Kennedy

Materials Science Lab's list of approved materials18 and are not included in Appendix C of NSTS

08242 as approved for general use in and around the orbiter vehicles. USA did not obtain a

Material Use Permit allowing the use of either material. The Kennedy Materials Sciences Lab

previously identified the Mystik 7000 tape as a contributing factor to a fire that occurred near one of

the orbiter vehicles in 1995 (see page 11 for details).

Without test data for these PFA’s, USA management is unable to identify the specific flammability

resistance, ESD rate, and hypergolic compatibility properties for each material, making it impossible

to effectively manage the associated risks. A full description of the PFA’s, testing information, and

Material Use Permit data is provided in Appendix E of this report.

Control Over the Use of PFA’s

 

18 Armalon is a trade name and, without additional information, we were unable to determine whether the

Kennedy Materials Science Lab or other NASA locations have tested the specific material in use. MAPTIS

contained flammability, toxicity, and thermal vacuum stability test data for Mystik 7000 tape; however, the test

results do not clearly state whether the tape passed or failed required tests.

Armalon

fabric

Mystik

7000
7

The inadequate control over the use of PFA’s in and around the orbiter vehicles resulted from (1)

inadequate USA procedures for ensuring the safe use of PFA’s, (2) Kennedy Shuttle Safety

Office’s limited oversight of USA’s use of PFA’s, and (3) incomplete NASA PFA approval and

testing records.

USA Safety Procedures for the Use of PFA’s. USA did not have adequate procedures in place

to ensure the safe use of PFA’s in and around the orbiter vehicles as required by the SFOC. USA

(1) had unclear procedures regarding when to use a Material Use Permit or a safety variance and

allowed M&P personnel, rather than safety professionals, to make decisions regarding the safe

control and use of PFA’s and (2) significantly changed its material safety procedures without

notifying NASA.

• Use of a Material Use Permit or a Safety Variance. Where circumstances dictate, USA

may use PFA’s not on the approved lists by obtaining a Material Use Permit, safety variance, or

both.19 The requirements for safety office involvement and the

preparation of a risk assessment20 differ significantly between a Material Use Permit and a

safety variance as shown in the following:

Key Differences Between a Material Use Permit and a Safety Variance

Document Kennedy or USA Safety Office Involvement. Risk Assessment

Material Use Permit Only if the USA M&P engineer specialist

determines that safety office involvement is

necessary.

Not required

Safety Variance Kennedy and USA safety office approval is

required.

Required

While the requirements of the Material Use Permit and safety variance process differ, USA’s

procedures are unclear regarding when one procedure is more appropriate than the other.

According to USA procedures, a USA M&P representative is responsible for approving or

disapproving a Material Use Permit when an organization wishes to use a previously

 

19 As an example of the use of both a Material Use Permit and a variance, on February 13, 1996, Kennedy and

USA signed Material Use Permit 96-005, allowing the use of Fromelt Saf-T-Vu plastic film. The film does not meet

the safety requirements regarding flammability resistance, as established by Appendix I of USA’s GSOP 5400

and Chapter 7 of the Kennedy Safety Handbook. In 1999, Kennedy and USA also issued safety variance 99-028

for the same material.

20 A risk assessment is a process of identifying all risks involved in a certain operation and the likelihood of

those risks occurring. NASA Procedures and Guidelines 8715.3, “NASA Safety Manual,” dated January 24,

2000, states that the primary purpose of risk assessment is to identify and evaluate risks to support

decisionmaking regarding actions to ensure safety and mission success.
8

unapproved PFA in and around the orbiter vehicles.21 The USA M&P engineer specialist

determines whether the proposed use of the material poses a hazard. The M&P engineer

specialist does not seek Kennedy or USA Safety Office involvement and does not submit the

material to the Kennedy Materials Science Lab for testing unless the engineer specialist

determines that hazards are present. In addition, USA’s Material Use Permit process does not

require the requesting organization to prepare a risk assessment for use of the PFA.

In contrast to the Material Use Permit process, USA’s safety variance procedures require the

organization wishing to use a previously unapproved PFA to prepare and submit for Kennedy

and USA Safety Offices’ approval, a safety variance and associated risk assessment.22

Although USA’s GSOP 540023 states that deviations from safety requirements must be

submitted as a safety variance, USA often used Material Use Permits for this purpose. As a

result, we could not clearly ascertain USA’s policy for obtaining a Material Use Permit rather

than a safety variance in order to use an unapproved PFA. USA did not consistently apply the

Material Use Permit and variance process and, therefore, did not obtain safety office approval

and did not prepare risk assessments to support its decisions to use unapproved materials in

Kennedy's Space Shuttle processing facilities. USA should have clear, uniform procedures for

using previously unapproved PFA's, including defining when it is appropriate to use a Material

Use Permit or a variance. The procedures should also identify the review and approval

requirements of both the Kennedy Shuttle Safety Office and USA Safety Office for Material

Use Permit or variances.

• USA’s Changed Material Safety Procedures.24 In a September 28, 2000, meeting with

USA M&P and safety officials, we made reference to Revision C of GSOP 5400, the then

current version of the document. During that meeting, we pointed out that GSOP 5400

required risk assessments and tests of all PFA’s. On October 3, 2000, USA made changes to

Revision C of GSOP 5400, stating that as a result of our audit, changes were necessary to

clarify existing policies. By modifying the document, USA omitted the two sections that

required risk assessments, including tests of flammability resistance, ESD rate, and hypergolic

compatibility, prior to using any

 

21 Since 1990, Kennedy or USA M&P personnel have prepared and approved 114 Material Use Permits of which

11 are related to PFA’s. 

22 From January 1, 1998, through July 13, 2000, Kennedy and USA safety officials approved 99 safety variances,

of which 3 were related to PFA’s.

23 GSOP 5400 is the USA document that specifies and establishes safety policies and procedures required during

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

24 Because the SFOC is a performance-based contract, USA may change its operating procedures without

seeking or receiving NASA approval unless such change increases the risk beyond an acceptable level or

directly violates a NASA or Kennedy requirement. USA, however, must submit to the Kennedy Shuttle Safety

Office, a rationale and risk assessment for changes to operating procedures. Two weeks after USA revised its

materials safety procedures, the Kennedy Shuttle Safety Office had not yet received notification of the changes

and was unaware that USA had instituted new procedures.
9

plastic film and adhesive tape.25 In effect, USA changed its procedures concerning PFA's

rather than comply with the testing and risk assessment requirements. Additionally, USA had

not notified Kennedy Shuttle Safety Office officials of the significant changes in USA material

safety procedures. USA should reestablish the requirements on PFA testing and risk

assessments in GSOP 5400 to ensure that it is compliant with NASA and Kennedy safety

policies and SFOC requirements.

As required by the SFOC, USA should have documented safety procedures in place for assessing

ground operations and maintenance activities for hazards such as untested PFA’s and for protecting

personnel and property from those hazards.

Kennedy Shuttle Safety Office Oversight of USA. The NASA Kennedy Shuttle Safety Office

was not actively involved in overseeing USA’s PFA usage as stipulated in the SFOC. The

Kennedy Shuttle Safety Office’s surveillance procedures did not include steps for gaining insight into

USA’s material selection and usage. Kennedy Shuttle Safety Office personnel were unaware that

(1) the USA M&P engineer specialist frequently approved Material Use Permits without consulting

either the USA or Kennedy Shuttle Safety Offices, (2) USA did not have the Kennedy Materials

Science Lab test all PFA’s, and (3) USA made significant changes to its materials safety

procedures. Also, Kennedy Shuttle Safety Office personnel erroneously believed that, at a

minimum, USA tests all new, unapproved PFA’s for flammability resistance. As required by the

SFOC, the Kennedy Shuttle Safety Office personnel must perform surveillance and gain better

insight into USA’s use and control of PFA’s by reviewing all variances, Material Use Permits, and

procedure changes. Improved insight will help ensure the safe use of PFA’s.

Approved Material and Test Records. There is no centralized list of approved materials and no

test records for some materials in use in and around the orbiter vehicles. We identified several,

often conflicting, sources of approved materials and requirements regarding material selection,

testing, and control. Appendix I of USA’s GSOP 5400 and Chapter 7 of the Kennedy Safety

Practices Handbook state that current approved adhesive tape and plastic film lists are on the

Kennedy Materials Science Division Intranet. However, USA M&P personnel also refer to

Appendix C of NSTS 08242, “Limitations for Non-flight Materials and Equipment Used In and

Around the Space Shuttle Orbiter Vehicles”; Material Use Permit and safety variance files; and the

MAPTIS when selecting PFA’s for use in Kennedy's Space Shuttle processing facilities. As a

result, there are at least five sources used for identifying approved materials, whereas Kennedy

policy references only the Kennedy Materials Science Division Intranet as the source of approved

materials. In addition, our review of MAPTIS showed that it did not clearly indicate whether

 

25 Prior to the changes of October 3, 2000, Appendix I and Section 2.21 of GSOP 5400, Revision C, required users

to obtain test data from the Kennedy Materials Science Lab before using a PFA in order to verify the material’s

performance and to aid in material selection. In contrast, the revised version of Revision C and Revision D of

GSOP 5400, dated November 15, 2000, state that PFA testing is required only during the Material Use Permit

process if material uses are hazardous or controlled. Also, the revised Appendix I specifies that only selection of

PFA’s for use in and around the obiter vehicles shall comply with the Material Use Permit approval process,

which does not require a safety assessment and does not require approval by the Kennedy or USA Safety

Offices.
10

materials had passed or failed required tests. The Director, John F. Kennedy Space Center, should

establish one centralized list of materials approved for use in and around the orbiter vehicles, with

reference to all associated testing records. 

Effects of Inadequate Control Over PFA’s

Without active Kennedy Shuttle Safety Office and USA Safety Office involvement, USA has neither

conducted an assessment of risk nor developed appropriate safety procedures for the use of

PFA’s. This hinders USA's and NASA’s ability to effectively manage the potential risks and

hazards associated with the use of PFA’s.

A Kennedy Materials Science Lab official, who is responsible for conducting required tests of

PFA’s and other materials, stated that using PFA’s that have never been tested could be

catastrophic from a safety standpoint. He opined that USA should, at a minimum, request tests of

flammability resistance for new or unapproved PFA’s intended for use in and around the orbiter

vehicles. He also stated that Kennedy and USA Safety Offices should be involved in the process of

determining whether a PFA or its proposed use is potentially hazardous.

USA acknowledged the potentially unsafe nature of PFA’s by stating in GSOP 5400, Revision D,

the following warning regarding ESD rate, flammability resistance, and improper use of adhesive

tapes and plastic films:

If a flammable adhesive tape is used to join two thin sheets of plastic that

meet flammability requirements, and if the tape accidentally ignites, it (and its

adhesive) can act as a path to quickly propagate the flame from one edge to

the other of the normally self-extinguishing plastic film. . . . When pulling

tape from its roll or any surface to which the tape is adhered, pull slowly to

minimize electrostatic charge build-up.26

Fires involving PFA’s have occurred in Kennedy facilities that house the Space Shuttle orbiters and

other hardware and equipment.

• In August 1998, a fire in USA's Kennedy Logistics Support Facility started when a spark

ignited gases in a plastic bag that held lithium batteries.27 The fire damaged 196 items including

cables, components, batteries, and test equipment and resulted in $133,568 in damages.

• In May 1995, a fire occurred in the Orbiter Processing Facility as a direct result of PFA’s that

did not meet ESD standards. The fire caused damage to Orbiter Vehicle-105’s thruster and

surrounding tiles and endangered three technicians. According to the official mishap report, five

 

26 GSOP 5400 states that Kennedy Materials Science Lab tests of some tapes showed that voltages in excess of

10,000 volts (at 30-percent relative humidity) result when a user pulls the tape from its roll. The voltage can

remain for a significant time. Under some circumstances, surface rubbing of affixed tape can result in buildup of

voltages in excess of 20,000 volts.

27 USA's Kennedy Logistics Support Facility houses about 500 NASA and contractor personnel and 190,000

Space Shuttle hardware parts.
11

of the seven PFA’s involved in the mishap, including Mystic 7000 tape, failed ESD tests

conducted by the Kennedy Materials Science Lab after the fire.28

The two fires clearly indicate a need to ensure that all PFA's used in Kennedy's Space Shuttle

processing facilities are adequately tested and approved for use by the appropriate safety

professionals. The Kennedy Shuttle Safety Office should appropriately assess whether the materials

listed in Appendix E of this report are properly used and controlled.

Summary

The orbiter vehicles along with the workforce that helps to maintain them and the supporting

infrastructure are core elements of the Agency’s mission. NASA must do everything reasonably

possible to protect these capabilities. As the NASA Administrator stated in his January 1999

message on safety, NASA must become informed risk takers by identifying, understanding, and

managing risk in all that is done. As shown through prior mishaps, inadequate control of PFA’s in

the facilities that house the orbiters and other components of the Space Shuttle can be very risky.

NASA must effectively manage those risks by first identifying the characteristics of the PFA’s

through testing and then

performing assessments to ensure that the materials are used safely based on the identified

characteristics. To help achieve this, NASA and USA must have clear procedures in place that

include involvement by the appropriate safety professionals.

Recommendations, Management’s Response, and Evaluation of

Response

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

1. Clarify the procedures for using Material Use Permits and safety variances for

PFA’s that are not on the approved list. The procedures should include appropriate

NASA or USA safety office review and approval of all Material Use Permits and

variances.

Management’s Response. Partially concur. An inter-Center team will review existing

requirements for the use of PFA's. The team will provide recommended documentation

 

28 Mishap investigators concluded that the most probable cause for ignition of the hypergolic fuel present was

the generation of an electrostatic spark between a technician’s tool and the fuel feedline fitting. The PFA’s used

for hypergolic fuel spill protection passed the electrostatic charge to the technician’s suit, gloves, and tool. The

mishap report stated that it is possible for a technician’s protective suit to generate voltages of sufficient

magnitude to produce an electrostatic arc from a tool held by that technician. The report further stated that the

situation is further complicated when PFA’s are present that generate a significant electrostatic charge that can

dissipate at a dangerous level.
12

changes to clarify or enhance the requirements, roles, and responsibilities for the use of PFA’s for all

programs at Kennedy. The complete text of management's response is in Appendix F.

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

recommendation. Our concern is that USA did not consistently apply the Material Use Permit and

variance process and, therefore, did not obtain USA or Kennedy Safety Office involvement in its

decisions to use unapproved materials in Kennedy's Space Shuttle processing facilities. The interCenter team’s recommendations should include clear procedures for ensuring either USA or

Kennedy Safety Office approval for the use of PFA’s that are not on an approved list, at Kennedy

Space Shuttle processing facilities, whether it be by way of a Material Use Permit or a variance.

The recommendation is resolved, but will remain undispositioned and open for reporting purposes

until corrective actions are completed.

NASA management also provided extensive comments on the finding that we address in Appendix

G.

2. Request USA to revise GSOP 5400 to reestablish the requirements for PFA testing

that were removed from Revision C on October 3, 2000, and obtain Kennedy Shuttle

Safety Office review of all proposed GSOP changes prior to implementation as

required by the SFOC.

Management’s Response. Partially concur. The inter-Center team will review GSOP 5400 for

compliance with NSTS 08242 and Kennedy Handbook 1710.2 requirements for the use of PFA’s.

All required documentation changes will be implemented to assure compliance with NASA

requirements (see Appendix F).

Evaluation of Management’s Response. Management’s planned action is not responsive to the

recommendation. Kennedy did not specifically address corrective actions to ensure that the

Kennedy Shuttle Safety Office reviews all proposed GSOP changes prior to implementation. The

audit determined that USA made significant changes to GSOP 5400 regarding the testing and

control of PFA’s without notifying the Kennedy Shuttle Safety Office. Section A of the SFOC

states that, “the contractor shall keep NASA continually informed about all concerns and issues,

particularly those related to safety and mission success.” Instituting a procedure that requires the

Shuttle Safety Office to review all proposed changes to USA’s GSOP would ensure compliance

with the SFOC and improve surveillance over USA’s operations. Therefore, we request that

management provide additional comments that address whether the Kennedy Shuttle Safety Office

will review all proposed GSOP changes prior to implementation by USA. The additional comments

should also include an estimated completion date for planned corrective actions. The

recommendation is unresolved and will remain undispositioned and open for reporting purposes.

3. Direct Kennedy Shuttle Safety Office personnel to be more actively involved in the

safe use of PFA’s by (a) determining whether potential hazards are present in
13

operations, (b) reviewing and approving Material Use Permits or variances that allow

the use of materials that have failed required tests or have not been tested, and (c)

increasing surveillance of PFA usage in and around the orbiter vehicles and other

elements of the Space Shuttle.

Management’s Response. Partially concur. Kennedy has added a periodic internal audit of the

PFA process for the Shuttle that is scheduled to be performed in July 2001. Internal and

independent verification audits will have a special focus on the use of PFA’s (see Appendix F).

Evaluation of Management’s Response. Management’s planned action is not fully responsive

to the recommendation. Kennedy did not specifically address corrective actions to ensure that the

Kennedy Shuttle Safety Office becomes more actively involved in the safe use of PFA’s by (1)

determining whether potential hazards are present in operations and (2) reviewing and approving

Material Use Permits or variances that allow the use of materials that have failed required tests or

have not been tested. As discussed in the report, the USA M&P engineer specialist (who is not a

safety engineer) had sole responsibility for determining whether the proposed use of a specific PFA

posed a hazard. The M&P engineer did not seek Kennedy or USA safety office involvement and

did not submit materials to be tested unless he determined that hazards were present. Having a

safety engineer review the proposed use of any PFA’s not on an approved list would help ensure

the safe use of all PFA’s in Kennedy's Space Shuttle processing facilities. Therefore, we request

that management provide additional comments on how it will ensure that the Kennedy Shuttle Safety

Office determines whether potential hazards are present in operations and reviews and approves all

Material Use Permits or variances that allow the use of materials that have failed required tests or

have not been tested. The additional comments should also include an estimated completion date

for planned corrective actions. The recommendation is unresolved and will remain undispositioned

and open for reporting purposes.

4. Develop one centralized and approved list of PFA’s approved for use in and around

the orbiter vehicles in Kennedy's Space Shuttle processing facilities.

Management’s Response. Partially concur. The inter-Center team will assess and provide

recommendations to assure timely access to PFA materials evaluations and/or test results performed

at the NASA Centers (see Appendix F).

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

recommendation. During the audit, we identified five sources for identifying materials approved for

use in and around the orbiter vehicles. The five sources were the (1) Appendix I of USA’s GSOP

5400, (2) Chapter 7 of the Kennedy Safety Practices Handbook (both state that current approved

adhesive tape and plastic film lists are on the Kennedy Materials Science Division Intranet), (3)

Appendix C of NSTS 08242, (4) Material Use Permit and safety variance files, and (5) the

MAPTIS. If Kennedy and the Space Shuttle Program recognize NSTS 08242 as the definitive list

of PFA’s approved for use in and around the orbiter vehicles, then the inter-Center team should

ensure that this is known by all personnel involved with PFA use. The inter-Center team should

further ensure that the list of approved PFA's in NSTS 0842 has a clear audit trail to all associated
14

Material Use Permits, variances, and testing records. The recommendation is resolved, but will

remain undispositioned and open for reporting purposes until corrective actions are completed.

5. Direct the Kennedy Shuttle Safety Office to perform appropriate assessments on

the use and control of the materials listed in Appendix E of this report.

Management’s Response. Concur. Appendix E has been reviewed and all 30 items have been

verified to be authorized for use by NSTS 08242 or referenced subtier documents (see Appendix

F).

Evaluation of Management’s Response. The action taken by management is responsive to the

recommendation. Kennedy stated in its response to the draft report that the test records for

materials tested by other NASA Centers were not readily accessible. We request that Kennedy

provide us the test records when they become available. The recommendation is resolved, but will

remain undispositioned and open for reporting purposes until corrective actions are completed.
15

Appendix A. Objectives, Scope, and Methodology

Objectives

The overall audit objective is to evaluate the United Space Alliance (USA) safety procedures for

NASA’s Space Flight Operations Contract (SFOC). The specific objective related to this report

was to determine whether potentially unsafe materials used in contract performance are properly

controlled.

The remaining objectives, which will be discussed in separate reports, are to determine whether:

• NASA is performing effective oversight of USA’s safety program and

• safety responsibilities between USA and NASA are clearly defined.

Scope and Methodology

To accomplish our objectives, we:

• Discussed materials testing, control, and approval procedures with John F. Kennedy Space

Center (Kennedy) Materials Science Lab personnel and NASA and USA Materials and

Processes (M&P) and safety officials.

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

approval procedures.

• Toured the Vehicle Assembly Building; Hypergolic Maintenance Facility; Rotation,

Processing, and Surge Facility; and high bays 1, 2, and 3 of the Obiter Processing Facility

during the period July through October 2000.

• Queried the USA safety variance database and identified and reviewed all safety variances

issued by USA from January 1, 1998, through July 13, 2000.

• Compared the plastic films, foams, and adhesive tapes (PFA’s) we observed in use with

various sources of approved PFA’s and test results. The various sources of approved

PFA’s and test results were the Kennedy Materials Science Lab Intranet, all

Material/Equipment Usage Permit (Material Use Permits) issued to date, USA safety

variances for 1998 through 2000, and test data in Marshall’s Materials and Processes

Technical Information System (MAPTIS).

• Compiled a list of 30 PFA’s that the Kennedy Materials Science Lab has not tested for

flammability resistance, electrostatic discharge (ESD) rate, or hypergolic compatibility but

that USA used in and around the orbiter vehicles.
16

Appendix A

Management Controls Reviewed

We reviewed management controls relative to procedures for controlling the use of potentially

unsafe materials in and around the Space Shuttle orbiter vehicles. We determined that controls

need to be strengthened to ensure that the Kennedy and USA safety offices are actively involved in

overseeing PFA usage through a definitive procedure for control of such materials during Space

Shuttle processing under the SFOC. This issue is discussed in detail in the finding section of the

report.

Audit Field Work

We conducted field work from July 2000 through May 2001 at NASA Headquarters and

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

standards.
17

Appendix B. Summary of Prior Audit Coverage

“Space Shuttle Program Management Safety Observations,” Report Number

IG-01-017, March 23, 2001. As part of the ongoing audit of the United Space Alliance (USA’s)

safety procedures under NASA’s Space Flight Operations Contract (SFOC), 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

SFOC. Specifically, we found that:

• the 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;

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

• USA’s Management Plan had not been updated commensurate with the changes to the

contract; and

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

Increased management attention to these areas will not only help ensure that NASA has an

adequate control structure in place to provide oversight of USA's safety operations under the

SFOC, but will also provide better control of more than $13 million in annual Space Shuttle

Program funds. We recommended that Johnson ensure that (1) surveillance plans address all

contract requirements for safety, (2) USA’s SFOC 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.

“Contract Safety Requirements at Kennedy Space Center and Marshall Space Flight

Center,” Report Number IG-00-035, June 5, 2000. The NASA Administrator stated in a

January 19, 1999, message that safety is the Agency’s highest core value. On February 26, 1999,

the Administrator emphasized the need for NASA contractors to be supportive of and accountable

for safety. The overall objective of the audit was to evaluate the safety procedures of NASA

contractors. We found that NASA was not applying existing basic safety provisions such as

required contract safety clauses, contractor safety plans at contract award, and Center safety office

involvement in the procurement process to 15 out of 25 contracts that we reviewed at Kennedy and

Marshall. As a result, NASA contractors including some involved in hazardous operations may not

be supporting the same safety goals as NASA. We recommended that Kennedy and Marshall

management identify all open contracts that either involve potentially hazardous operations or

exceed $1 million and determine whether those contracts have the required safety clauses and

contractor safety plans. NASA concurred with our recommendations and implemented corrective

actions to ensure that all applicable contracts contained the required safety documentation.
18

Appendix B

“Safety Concerns with Kennedy Space Center’s Payload Ground Operations,” Report

Number IG-00-028, March 30, 2000. In February 1999, the House of Representatives

Committee on Science requested that the NASA Office of Inspector General (OIG) address

concerns related to the safety functions of Kennedy’s Payload Ground Operations Contract

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

Boeing Company (Boeing). In response to this request, we reviewed the contractor’s operations to

determine whether (1) safety responsibilities between Boeing and NASA had been clearly defined;

(2) hazardous materials were being used in Kennedy’s processing facilities; and (3) hazardous

materials, if used, were properly controlled. The audit identified that ground workers were using

potentially hazardous materials in Kennedy processing facilities without exercising proper control

and safety precautions. This condition existed because (1) Boeing safety personnel had not

performed adequate, contract-required inspections of the facilities; (2) Kennedy and Boeing safety

personnel had not reviewed Material Usage Agreements that authorized the use of noncompliant

materials; and (3) Kennedy and Boeing safety personnel did not perform risk analyses to support

the materials usage agreements. As a result, NASA lacks assurance that associated risks are

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

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

payloads, including International Space Station hardware and equipment. We recommended that

management (1) direct the contractor to perform analyses to support the use of all materials that do

not meet requirements for flammability and electrostatic discharge, (2) clarify instructions for

preparation of Materials Usage Agreements, and (3) increase surveillance of the contractor’s safety

office inspection procedures. NASA concurred with each recommendation and implemented a

number of procedures to control all noncompliant materials.

“Safety Considerations at Goddard Space Flight Center,” Report Number

IG-99-047, September 22, 1999. While conducting a broad evaluation of NASA’s safety

program, we identified issues requiring immediate management attention that could affect the safety

of Goddard Space Flight Center (Goddard) employees. Specifically, we determined that (1)

Goddard's various safety offices were not consolidated into one organization with a full-time

director; (2) the mishap reporting process did not ensure that the causes of all mishaps were

properly addressed and that all mishaps and related information were adequately reported; and (3)

contractor's safety records were not evaluated prior to contract award, as required by the NASA

Safety Manual. We recommended that the Goddard Center Director (1) evaluate the effectiveness

of the ongoing safety initiatives, (2) ensure that all mishaps are reported accurately and in a timely

manner and that the root causes are identified, and (3) establish procedures for reviewing contractor

safety records before contract award. Management concurred with each recommendation.
19

Appendix C. Materials Testing, Approval, and Control Requirements

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

plastic films, foams, and adhesive tapes:

NASA Space Transportation System 08242, “Limitations for Non-flight Materials and

Equipment Used In and Around the Space Shuttle Orbiter Vehicles,”

(NSTS 08242) Revision A, May 6, 1994. This standard contains lists of non–flight materials and

equipment approved for use as well as materials prohibited for use in and around the orbiter

vehicles. The standard also defines the NASA responsibilities for control of the specified materials

and equipment and establishes a procedure for effecting temporary or permanent changes to the

approved materials and equipment lists contained therein. Specifically, paragraph 4.1 of the

standard states that a United Space Alliance (USA) Materials and Process (M&P) representative

shall prepare a Material/Equipment Usage Permit (Material Use Permit) when a requesting engineer

wishes to use an unapproved PFA in and around the orbiters.

Where circumstances dictate, materials and equipment not on the approved

lists or quantities in excess of those specified may be used on a temporary

basis by means of a MUP [Material Use Permit].

NASA-STD-6001, “Flammability, Odor, Offgassing, and Compatibility Requirements and

Test Procedures for Materials in Environments that Support Combustion,” February 9,

1998. This standard establishes requirements for evaluation, testing, and selection of materials that

are intended for use in space vehicles, associated ground support equipment, and facilities used

during assembly, test, and flight operations. Materials intended for use in these situations must meet

the requirements of this document. The intent of the standard is to preclude unsafe conditions

related to flammability, odor, offgassing, and fluid compatibility. The standard requires, at a

minimum, tests of materials for flammability resistance.

Materials used in habitable areas of spacecraft, including the materials of the

spacecraft, stowed equipment, and experiments, must be evaluated for

flammability, odor, and offgassing characteristics. All materials used in

other areas must be evaluated for flammability characteristics [emphasis

added]. 

The standard further supports required risk assessments prior to the use of untested materials,

specifically:

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

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

configuration by analysis or testing.

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

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

steps to be followed by all organizational elements at Kennedy in the selection of
20

Appendix C

materials. Section 2.3 states that the Director of the Kennedy Safety and Mission Assurance

organization is responsible for ensuring that only approved materials are used, including those used

by contractors. Furthermore, the document states that engineers are responsible for selecting

materials to be used in and around the orbiter vehicles in accordance with NSTS 08242. The

document also identifies the Kennedy Materials Science Lab, a branch of the Materials Science

Division, as the organization responsible for materials testing at Kennedy.

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

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

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

maintenance activities at Kennedy. The provisions of the handbook apply to all organizational

elements at Kennedy, to their associated contractors and subcontractors, and to other Government

agencies and their contractors operating at Kennedy. The handbook requires that when an

organization cannot meet a safety requirement, it shall provide a request for a variance to the

Kennedy Safety Office.29 Chapter 7, “Use of Plastic Films and Adhesive Tapes in Space

Shuttle/Payload Processing Areas,” contains provisions for use and testing of materials in and

around the orbiters. The chapter states, “Adhesive tapes and plastic films used in Kennedy Space

Center flight hardware processing facilities shall only be used for operations where they meet the

acceptance criteria for their specified use.” The chapter further states that current, approved

adhesive tape and plastic film lists are maintained by the Kennedy Materials Science Lab and are

available by accessing the Materials Science Division's Intranet.

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

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

safety criteria and establishes requirements for ground processing of Shuttle payloads and

associated ground support equipment. Section 4.3.9, “Ground Support Equipment Materials,”

pertains to the approval, use, and control of PFA’s by stating that flammable materials and staticproducing materials shall be kept to a minimum in all payload-processing areas. Furthermore,

plastic films shall be selected from the Launch Site Safety Office approved plastics list. The

organization wishing to use a plastic film that is not on the approved list must submit to the Launch

Site Safety Office a sample of the material for test/evaluation and approval.

 

29 Kennedy Handbook 1710.2, Chapter 1, Section 106, "Variances,” states that when a requirement of the

Handbook cannot be met, an organization shall request a variance from the Director, Safety and Mission

Assurance. Although Section 106 does not specifically state that the Kennedy Director of Safety and Mission

Assurance shall approve the variance, Section 103 states that the Kennedy Center Director has tasked the

Director, Safety and Mission Assurance to ensure compliance with the Kennedy safety program. Under

Kennedy’s recent reorganization, the Office of Director, Safety and Mission Assurance no longer exists and has

been replaced by the Associate Director, Safety and Mission Assurance under the Safety, Health and

Independent Assessment Directorate.
21

Appendix C

Use of flammable materials and static-producing materials shall be kept to a

minimum in all payload-processing areas. If any plastic film is to be used,

the material shall be selected from the LSSO [Launch Site Safety Office]

approved plastics list. . . . If a plastic film is not on the approved list, a

sample (minimum 1 square yard) shall be submitted to the LSSO for

test/evaluation and approval.

USA’s Ground Safety Operating Procedures (GSOP) 5400, Revision C, January 20, 2000.

As stated in the introduction to Volume I of GSOP 5400, Revision C, “supplements Kennedy

Space Center Safety, Reliability, Maintainability, and Quality Assurance Programs, and Kennedy

Handbook 1710.2, “Kennedy Space Center Safety Practices Handbook” where necessary.”

Furthermore, the document establishes safety policies and procedures required during operations

and maintenance activities at USA-designated areas of Kennedy. Appendix I states that current

approved adhesive tape and plastic film lists are maintained by the Kennedy Materials Science Lab

and are available by accessing the Materials Science Division's Intranet. In addition, the appendix

states:

Adhesive tapes and plastic films used in Kennedy flight hardware

processing facilities shall only be used for operations where they meet the

acceptance criteria for their specified use.

Revision C of USA’s GSOP 5400, Section 2.21, “Use of Flame Retardant, Anti-static Plastic

Films/Tapes in STS [Space Transportation System]/Payload Processing Areas,” states:

All thin plastic films and adhesive tapes used in the STS and Payload areas must be approved by the

Kennedy Space Vehicle Safety and Reliability Division. The listing source for safety-approved

plastic films and adhesive tapes for unrestricted and restricted use appears in Appendix I of this

volume. Use of thin plastic film or adhesive tape other than those listed for controlled use, will

depend on a safety assessment of testing results and use application.

GSOP 5400 further provides that organizations desiring to modify the list of approved PFA’s must

submit a safety assessment to the Kennedy Safety Office. Sections 2.21.1 and 2.21.2 state that the

required safety assessment should consist of tests that measure the material’s safety characteristics.

Specific measurements shall include flammability resistance, ESD rate, and hypergolic compatibility.

USA’s Standard Practice Instruction, SP-001(2)K, “Nonflight Materials and Equipment

Control During Orbiter Ground Operations,” August 17, 1999. The purpose of this document

is to implement material and equipment requirements and limitations stated in NSTS 08242, provide

control procedures for ground operations, and describe the method to process Material Use

Permits for temporary or permanent changes to existing materials and equipment lists. Specifically,

the document states that if a
22

Appendix C

material is not in the NSTS 08242 list of approved materials and is required for performing work,

requestors must obtain usage approval from a USA M&P engineer. As stated in Section 6.3, USA

M&P engineers are responsible for (1) approving or disapproving Material Use Permits and (2)

determining whether the Material Use Permit involves hazardous materials. 30 M&P engineers are

required to submit Material Use Permits to USA’s Safety Office for concurrence only if hazardous

materials are involved. This document does not require a requesting organization to prepare a risk

assessment.

USA’s Standard Practice Instruction, SP-003(2)K, “Nonflight Materials and Equipment

Control During External Tank/Solid Rocket Booster Operations,” March 2, 1999. The

purpose of this document is to specify nonflight materials and equipment requirements and limitations

and to provide procedures for controlling materials and equipment in and around the external tank

and solid rocket boosters during ground operations. The document states that any use of plastic

sheet materials and tapes and spark- or heat-producing devices in and around the external tank and

solid rocket boosters is to comply with GSOP 5400 requirements.

USA’s Standard Practice Instruction, SF-507(8)K, “Safety Variances,”

December 14, 1999. This document establishes responsibilities and procedures for requesting,

processing, and approving safety variances. The document requires that when an organization

cannot meet an established safety requirement, the organization should request a temporary safety

variance from both the Kennedy and USA Safety Offices. The request for the safety variance must

include a detailed risk assessment that will be reviewed and approved by both the Kennedy and

USA Safety Offices.

 

30 Materials may be hazardous due to flammability, ignition source, toxicity, corrosion, or chemical reaction.

Hazardous materials may also involve limitations on their use such as location, quantity, proximity to other

materials or heat sources, need for protective equipment, or provisions for monitoring or handling.
23

Appendix D. Examples of PFA Usage In and Around the Orbiter Vehicles

Figure D-3. ACLAR plastic film1 covering LO2 17” disconnect and adhered to Orbiter Vehicle-105

with RE22 tape,2 October 17, 2000.

1 A United Space Alliance (USA) Materials and Process (M&P) engineer specialist identified this material as

ACLAR plastic film. The Kennedy Materials Science Lab has tested ACLAR, 22A, 22C, and 33C. The film

passed flammability tests, but based on the results of the electrostatic discharge (ESD) rate test, Kennedy

determined that ACLAR is not permitted where ESD buildup or discharge is required to be minimal. Also, the lab

cautions users to consider the material’s hypergol (rocket fuel) compatibility (the material’s reaction when

exposed to hypergols) prior to use near hypergolic fuels. ACLAR plastic film is included in Appendix C of NSTS

08242, “Limitations for Non-flight Materials and Equipment Used In and Around the Space Shuttle Orbiter

Vehicles,” as approved for general use in and around the orbiter vehicles. However, its usage is limited to

covering line connections and line closures and wrapping leaking hydraulic lines. Marshall’s Materials and

Processes Technical Information System (MAPTIS) contained flammability, flash/fire, mechanical impact, and

toxicity test data for ACLAR 22A. MAPTIS also contained flammability and mechanical impact test data for

ACLAR 22C. However, the test results do not clearly state whether these films passed or failed. MAPTIS

contained no test data for ACLAR 33C.

2 A USA M&P engineer specialist identified this material as RE22 tape. The Kennedy Materials Science Lab has

not tested RE22 tape, and the lab has not received a request for testing. As a result, this tape is not on the lab’s

list of approved PFA’s. The tape is also not in Appendix C of NASA Standard 08242, “Limitations for Non-flight

Materials and Equipment Used In and Around the Space Shuttle Orbiter Vehicles,” (NSTS 08242) as approved

for general use in and around the orbiter vehicles, and there is no current Material Use Permit approving the use

of RE22 tape. MAPTIS contained no test data for this tape.

RE22 tape

ACLAR

plastic film
24

Appendix D

Figure

D-4.

Lectrolite Duotone green/black plastic film1 held to Orbiter Vehicle-105 Orbital Maneuvering System

pod by 3M 363 tape,2 October 17, 2000.

1 A USA M&P engineer specialist identified this material as Lectrolite Duotone green/black plastic film. The

Kennedy Materials Science Lab has tested this film. The film passed flammability resistance, ESD rate,

hypergolic ignition, and breakthrough resistance tests and is approved for use in all Kennedy flight hardware

processing facilities. The USA M&P engineer specialist stated that Lectrolite Duotone green/black film has the

same properties as Lectrolite Duotone blue/black film. However, in April 1996, USA requested and Kennedy

approved a safety variance for this material, stating that it consistently failed flammability tests. Lectrolite plastic

film is included in Appendix C of NSTS 08242 as approved for general use in and around the orbiter vehicles, and

there are no limitations on its usage. MAPTIS contained no test data for Lectrolite film.

2

 A USA M&P engineer specialist identified this material as 3M 363 tape. The Kennedy Materials Science Lab

has tested the tape. The tape passed flammability resistance, ESD rate, and hypergolic compatibility tests and is

approved for use in all Kennedy flight hardware processing facilities. The 3M 363 tape is not included in

Appendix C of NSTS 08242 as approved for general use in and around the orbiter vehicles. MAPTIS contained

flammability, flash/fire, toxicity, odor, thermal vacuum stability, and cure test data for Scotch 363 tape. Scotch is

a registered trademark of the 3M Company.

tape
25

Appendix D

Figure

D-5.

Ensolite

natural

foam*

covering wing of Orbiter Vehicle-105, October 17, 2000.

* A USA M&P engineer specialist identified this material as Ensolite natural foam. The Kennedy Materials

Science Lab has tested this foam. The foam passed flammability tests, but is not permitted where electrostatic

buildup or discharge is required to be minimal. The lab also cautions users to consider the foam’s test reaction

to hypergols (rocket fuel) prior to use near hypergolic fuels. Ensolite foam is included in Appendix C of NSTS

08242 as approved for general use in and around the orbiter vehicles. MAPTIS contained flammability, flash/fire,

toxicity, odor, and thermal vacuum stability test data for Ensolite foam. However, the test results do not clearly

state whether these films passed or failed. 

Foam on

orbiter wing
26

Appendix E. Material Test Results

No.

Material &

Manufacturer

Marshall Material and

Processes Technical

Information System (MAPTIS)

Test Data Audit Observations

Plastic Films

1 Saran 8

Dow Chemical

No test data available through

MAPTIS.

Listed in Appendix C of NASA Standard 08242,

“Limitations for Non-flight Materials and Equipment Used

In and Around the Space Shuttle Orbiter Vehicles,” (NSTS

08242) as approved for general use. Not tested by the

Kennedy Materials Science Lab. The lab has not received

a request for testing.

Foams

2 Eccosorb AN-73

Emerson &

Cummings

MAPTIS contained thermal

vacuum stability test data only

for Eccosorb AN series foam.

No flammability data available.

Listed in Appendix C of NSTS 08242 as approved for

general use. Not tested by the Kennedy Materials Science

Lab. The lab has not received a request for testing.

3 Eccosorb AN-77

Emerson &

Cummings

MAPTIS contained thermal

vacuum stability test data only

for Eccosorb AN series foam.

No flammability data available.

Listed in Appendix C of NSTS 08242 as approved for

general use. Not tested by the Kennedy Materials Science

Lab. The lab has not received a request for testing.

4 Omar 100

Unavailable

No test data available through

MAPTIS.

Listed in Appendix C of NSTS 08242 as approved for

general use. Not tested by the Kennedy Materials Science

Lab. The lab has not received a request for testing.

5 Polyfoam 2060

(BIR-60-E)

Unavailable

No test data available through

MAPTIS.

Listed in Appendix C of NSTS 08242 as approved for

general use. Not tested by the Kennedy Materials Science

Lab. The lab has not received a request for testing.

Adhesive Tapes

6 L-T-80

Unavailable

No test data available through

MAPTIS.

Listed in Appendix C of NSTS 08242 as approved for

general use. Not tested by the Kennedy Materials Science

Lab. The lab has not received a request for testing.

7 3M 4008

3M Co.

No test data available through

MAPTIS.

Listed in Appendix C of NSTS 08242 as approved for

general use. Not tested by the Kennedy Materials Science

Lab. The lab has not received a request for testing.

8 3M 4046Y

3M Co.

No test data available through

MAPTIS.

Listed in Appendix C of NSTS 08242 as approved for

general use. Not tested by the Kennedy Materials Science

Lab. The lab has not received a request for testing.
27

Appendix E

No.

Material &

Manufacturer MAPTIS Test Data Audit Observations

9 3M 4408

3M Co.

MAPTIS contained

flammability and flash/fire test

data for Scotch 4408 tape, a

registered trademark of 3M Co.

Listed in Appendix C of NSTS 08242 as approved for

general use. Not tested by the Kennedy Materials Science

Lab. The lab has not received a request for testing.

10 Permacel 222

Permacel/Nitto

Denko

MAPTIS contained

flammability, toxicity, and

thermal vacuum stability test

data.

Listed in Appendix C of NSTS 08242 as approved for

general use. Not tested by the Kennedy Materials Science

Lab. The lab has not received a request for testing

11 CHR K-250

Unavailable

No test data available through

MAPTIS.

Listed in Appendix C of NSTS 08242 as approved for

general use. Not tested by the Kennedy Materials Science

Lab. The lab has not received a request for testing.

12 CHR K-350

Unavailable

No test data available through

MAPTIS.

Listed in Appendix C of NSTS 08242 as approved for

general use. Not tested by the Kennedy Materials Science

Lab. The lab has not received a request for testing.

13 Permacel 252

Permacel/Nitto

Denko

MAPTIS contained

flammability, flash/fire, toxicity,

odor, thermal vacuum stability,

and cure test data.

Listed in Appendix C of NSTS 08242 as approved for

general use. Not tested by the Kennedy Materials Science

Lab. The lab has not received a request for testing.

14 CHR M66

Unavailable

No test data available through

MAPTIS.

Listed in Appendix C of NSTS 08242 as approved for

general use. Not tested by the Kennedy Materials Science

Lab. The lab has not received a request for testing.

15 Mystik 6402

Allied Signal

No test data available through

MAPTIS.

Listed in Appendix C of NSTS 08242 as approved for

general use. Not tested by the Kennedy Materials Science

Lab. The lab has not received a request for testing.

16 3M 800

3m Co.

MAPTIS contained

flammability, toxicity, and odor

test data for Scotch 800 tape, a

registered trademark of 3M Co.

Listed in Appendix C of NSTS 08242 as approved for

general use. Not tested by the Kennedy Materials Science

Lab. The lab has not received a request for testing.

17 3M 4016

3M Co.

MAPTIS contained toxicity test

data for Scotch 4016 tape, a

registered trademark of 3M Co.

Listed in Appendix C of NSTS 08242 as approved for

general use. Not tested by the Kennedy Materials Science

Lab. The lab has not received a request for testing.
28

Appendix E

No.

Material &

Manufacturer MAPTIS Test Data Audit Observations

18 Mystik 7503

Allied Signal

MAPTIS contained

flammability, flash/fire, toxicity,

odor, thermal vacuum stability,

and cure test data.

Listed in Appendix C of NSTS 08242 as approved for

general use. Not tested by the Kennedy Materials Science

Lab. The lab has not received a request for testing.

19 Mystik 7505

Allied Signal

No test data available through

MAPTIS.

Listed in Appendix C of NSTS 08242 as approved for

general use. Not tested by the Kennedy Materials Science

Lab. The lab has not received a request for testing.

20 Mystik 7510

Allied Signal

No test data available through

MAPTIS.

Listed in Appendix C of NSTS 08242 as approved for

general use. Not tested by the Kennedy Materials Science

Lab. The lab has not received a request for testing.

21 3M 60

3M Co.

MAPTIS contained

flammability, toxicity, odor, and

thermal vacuum stability test

data for Scotch 60 tape, a

registered trademark of 3M Co.

Listed in Appendix C of NSTS 08242 as approved for

general use. Not tested by the Kennedy Materials Science

Lab. The lab has not received a request for testing.

22 3M 61

3M Co.

MAPTIS contained

flammability, flash/fire,

mechanical impact, toxicity,

odor, and thermal vacuum

stability test data for Scotch 61

tape, a registered trademark of

3M Co.

Listed in Appendix C of NSTS 08242 as approved for

general use. Not tested by the Kennedy Materials Science

Lab. The lab has not received a request for testing.

23 3M 62

3M Co.

MAPTIS contained

flammability, toxicity, odor,

thermal vacuum stability, and

cure test data for Scotch 62

tape, a registered trademark of

3M Co.

Listed in Appendix C of NSTS 08242 as approved for

general use. Not tested by the Kennedy Materials Science

Lab. The lab has not received a request for testing.

24 CHR HM-650

Unavailable

No test data available through

MAPTIS.

Listed in Appendix C of NSTS 08242 as approved for

general use. Not tested by the Kennedy Materials Science

Lab. The lab has not received a request for testing.

25 RB0159-002

Unavailable

No test data available through

MAPTIS.

Not tested by the Kennedy Materials Science Lab. The

lab has not received a request for testing. Material Use

Permit 94-007, dated June 27, 1994, specified use limited to

aft fuselage and exterior use.
29

Appendix E

No.

Material &

Manufacturer MAPTIS Test Data Audit Observations

26 Mystik 7367

Allied Signal

MAPTIS contained

flammability, flash/fire, volatile

condensable material, toxicity,

odor, thermal vacuum stability,

and cure test data.

Not tested by the Kennedy Materials Science Lab. The

lab has not received a request for testing. Material Use

Permit 95-013, dated June 14, 1995, specified use limited to

payload.

27 Permacel P-670

Permacel/Nitto

Denko

MAPTIS contained

flammability, toxicity, and

thermal vacuum stability test

data.

Not tested by the Kennedy Materials Science Lab. The

lab has not received a request for testing. Material Use

Permit 97-006, dated March 12, 1997, specified use limited

to crew compartment only.

28 Kalex 15036

urethane adhesive

Unavailable

No test data available through

MAPTIS.

Not tested by the Kennedy Materials Science Lab. The

lab has not received a request for testing. Not a true tape,

but an adhesive substance used to seal the nozzle vented

tube plug for processing and post landing leak checks.

Kennedy and USA safety officials signed Material Use

Permit 00-010, approving Kalex polyurethane adhesive,

because its use poses potential hazards such as eye, skin,

respiratory tract, and lung irritation.

29 Mystik 7000

Allied Signal

MAPTIS contained

flammability, toxicity, and

thermal vacuum stability test

data.

Observed in use on the tile near the landing gear of Orbiter

Vehicle-105. Not tested by the Kennedy Materials Science

Lab. The lab has not received a request for testing. NSTS

08242 references specification ML0601-9024, which

controls operations for the orbiter’s thermal protection

system. ML0601-9024 authorizes the use of this material

only in such operations.

30 RE22

Unavailable

No test data available through

MAPTIS.

Observed in use on Orbiter Vehicle-105. Not tested by the

Kennedy Materials Science Lab. The lab has not received

a request for testing. Not listed in Appendix C of NSTS

08242 as approved for general use.

31 Armalon

Fairprene Industrial

Products

MAPTIS contained

flammability, flash/fire,

mechanical impact, toxicity,

odor, and thermal vacuum

stability test data for one

material matching the

designation of Armalon and

only mechanical impact test

data for a second material

named Armalon. Both materials

are manufactured by Fairprene

Industrial Products.

Observed in use on Orbiter Vehicle-105. Not tested by the

Kennedy Materials Science Lab. The lab has not received

a request for testing. NSTS 08242 references specification

ML0601-9024, which controls operations for the orbiter’s

thermal protection system.

ML0601-9024 authorizes the use of this material only in

such operations.
30

Appendix F. Management’s Response
31

Appendix F

See Appendix G,

OIG Comment 1

See Appendix G,

OIG Comment 2

See Appendix G,

OIG Comment 3

See Appendix G,

OIG Comment 4

See Appendix G,

OIG Comment 5

See Appendix G,

OIG Comment 6
32

Appendix F

See Appendix G,

OIG Comment 7
33

Appendix F

See Appendix G,

OIG Comment 8

See Appendix G,

OIG Comment 9
34

Appendix F

See Appendix G,

OIG Comment 10

See Appendix G,

OIG Comment 11
35

Appendix F

See Appendix G,

OIG Comment 12

See Appendix G,

OIG Comment 13

See Appendix G,

OIG Comment 14
36

Appendix F

See Appendix G,

OIG Comment 15

See Appendix G,

OIG Comment 16

See Appendix G,

OIG Comment 17
37

Appendix F
38

Appendix F
39

Appendix G. Office of Inspector General Comments on

Management’s Response

John F. Kennedy Space Center (Kennedy) management provided the following comments in

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

Management's Comment. The draft report includes a flowchart for the use of plastic films,

foams, and adhesive tapes in and around the orbiters. Kennedy enclosed (see Appendix F) for our

consideration and inclusion in the report, a process flowchart that depicts the process that is defined

in NASA Standard 08242, “Limitations for Non-flight Materials and Equipment Used In and

Around the Space Shuttle Orbiter Vehicles,” (NSTS 08242). 

1. Office of Inspector General (OIG) Comments. The process flowchart in the body of the

audit report (page 4) reflects our understanding of the process flow for the safe use of PFA’s in and

around the orbiter as required by the Space flight Operations Contract (SFOC) and NASA and

Kennedy policies on the testing and control of PFA’s. The process flow as depicted in

management’s flowchart does not completely meet SFOC requirements because (1) there is no

testing data and results available for many of the materials listed in NSTS 08242 and (2) the

Materials and Processes (M&P) engineer’s decision as to whether a material would be used in a

hazardous operation did not include input from a safety engineer.

Management’s Comment. Kennedy’s review of the materials listed in the draft report

determined that all of them were used safely and that all were authorized for ground processing

usage by the Shuttle Program in NSTS 08242.

2. OIG Comments. Although management responded that it used all of the listed materials safely,

that was not the case during our audit field work. We identified 30 materials that United Space

Alliance (USA) was using in and around the orbiter vehicles for which there was no record of

testing data or Safety Office review and approval. On February 5, 2001, we presented this

information to the Kennedy Director of Shuttle Processing to share with his staff. When we met

with the Kennedy Director of Shuttle Processing on February 15, 2001, he did not know whether

USA used the materials safely but stated that he would have to perform further research. More

than 4 months later, management concluded that USA used the materials safely. However,

Kennedy was unable to present any evidence of materials testing from any NASA Center or test

facility. In our opinion, management should know at all times whether USA is safely using materials

in or around the orbiter vehicles. There should be a clear audit trail of testing data, safe use

requirements, and authorization for every material used in and around the orbiters. We found that

no such audit trail existed.
40

Appendix G

Management’s Comment. Some of the report’s conclusions were based on the premise that a

material cannot be used in and around the orbiter if that material fails any of the material tests.

3. OIG Comments. We take exception to management's statement. The report clearly states that

“Materials that meet NASA standards are placed on approved lists. Materials that do not meet

those standards can be used only after obtaining a Materials/Equipment Usage Permit (Material Use

Permit) or a safety variance, both of which require USA and Kennedy safety office approval.”

Management’s Comment. Much is noted in the report about fire, static control, and hypergolic

protection for catastrophic prevention purposes.

4. OIG Comment. The report discusses two fires involving PFA’s in Kennedy’s Shuttle

processing facilities in order to illustrate the potential effect of inadequate control of PFA’s and the

need for strong safety requirements. In addition to the two fires discussed in the report, another

incident occurred in April 2001 in the Orbiter Processing Facility that provides further evidence of

the need for improved fire and static control. According to the USA incident report on the April

2001 incident, vapors from a bottle containing a waterproofing agent ignited and could have caused

serious injury to processing personnel and/or significant damage to major essential flight elements.

The incident investigation team determined that a root cause of the incident was the use of materials

that had a high potential for electrostatic discharge (ESD).

Management’s Comment. Fire (flammability) control is performed through material sensitivity

regulation rather than restraint of the resultant flame propagation.

5. OIG Comment. This statement conflicts with NASA and USA requirements. Both NASA

and USA standards indicate that control of flame propagation must also be considered. NASA

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

Test Procedures for Materials in Environments that Support Combustion (NASA-STD-6001),"

requires the upward flame propagation test on all materials used in space vehicles, ground support

equipment, and facilities used during assembly, test, and flight operations. NASA-STD-6001 states

that the purpose of the upward flame propagation test is, “to determine if a material, when exposed

to a standard ignition source, will self-extinguish and not transfer burning debris, which can ignite

adjacent materials.” USA also acknowledged the need to control flame propagation of PFA’s by

stating in its Ground Safety Operating Procedures (GSOP) 5400, Revision D, “If a flammable

adhesive tape is used to join two thin sheets of plastic that meet flammability requirements, and if the

tape accidentally ignites, it (and its adhesive) can act as a path to quickly propagate the flame from

one edge to the other of the normally self-extinguishing plastic film.”
41

Appendix G

Management’s Comment. The materials identified in the report’s photographs are authorized for

the specific use shown in those photographs because they meet functionality requirements for the

particular application, and the appropriate program safety office had reviewed their selection at the

time.

6. OIG Comment. Neither the Armalon fabric nor the Mystik 7000 tape shown in Figure 2 of the

report are on the Kennedy Materials Science Lab's list of approved materials and are not included

in Appendix C of NSTS 08242 as approved for general use in and around the orbiter vehicles.

USA did not obtain a Material Use Permit allowing the use of either material, and there was no

record of either USA or Kennedy Safety office approval for either material.

The Kennedy Materials Science Lab had not tested the RE22 tape shown in Figure D-3. The tape

is not in Appendix C of NASA Standard 08242 as approved for general use in and around the

orbiter vehicles, and there is no current Material Use Permit approving the use of RE22 tape.

MAPTIS contained no test data for this tape and there was no record of either USA or Kennedy

Safety office approval for the RE22 tape.

Management’s Comment. Even though laboratory tests of Mystik 7000 tape and Armalon

indicate a static (ESD) generation concern, in this particular application, there is no static concern.

7. OIG Comment. The Mystik 7000 tape failed ESD testing and was cited as a contributing

cause to a fire in the Kennedy Orbiter Processing Facility. When we took the photograph of the

Mystik 7000 tape, there were no documented procedures/ restrictions in place and authorized by

either NASA or USA safety personnel to ensure the safe use of the material. The material was not

listed in NSTS 08242 or approved through a Material Use Permit or safety variance.

Management’s Comment. USA uses Standard Practice Instructions to identify to the workforce

the requirements and processes used during Shuttle processing.

8. OIG Comment. The OIG is aware of the separate requirements for using a Material Use

Permit as opposed to a variance. However, as stated in the report, USA’s procedures were

unclear regarding when one process is more appropriate than the other. In fact, we found at least

one example of issuance of both a Material Use Permit and a safety variance for the same material

(Fromelt Saf-T-Vu plastic film). Details on this example are provided in footnote 18 of the report.

By not consistently applying the Material Use Permit and variance process, USA did not always

obtain safety office approval and did not prepare risk assessments to support its decisions to use

unapproved materials in Kennedy's Space Shuttle processing facilities. Only the USA Materials

and Processes
42

Appendix G

(M&P) engineer specialist determined whether the proposed use of a material posed a hazard. The

M&P engineer specialist did not seek Kennedy or USA Safety Office involvement unless he

determined that hazards were present.

In addition, Material Use Permits did not always provide specific instructions and restrictions for the

use of PFA’s that did not meet NASA requirements. For example, on March 18, 1996, the

Kennedy Materials Sciences lab tested Kydex 100 thermoplastic sheets, and the material failed the

ESD test. Although USA issued a Material Use Permit for Kydex 100 on January 24, 2000, the

Material Use Permit log did not include any

special instructions to ensure that the material is used only when ESD is not a concern. USA should

have clear, uniform procedures defining when it is appropriate to use a Material Use Permit or a

variance to ensure that all materials are used safely.

Management’s Comment. Although NSTS 08242 and the USA material use process does not

require USA or NASA safety engineers to review and approve all Material Use Permits, the USA

safety engineer reviews all permits.

9. OIG Comment. Management did not provide support for this statement. The USA M&P

engineer specialist responsible for preparing the Material Use Permits stated that he asks for safety

engineer review only when he determines that the materials will be used in a hazardous operation.

Our review of the Material Use Permit file supported the USA M&P engineer’s statement.

Specifically, we found a safety engineer’s signature only on the Material Use Permits for materials

the engineer specialist determined would involve hazardous operations.

Management’s Comment. During the audit, it was discovered that the PFA section of GSOP

5400 needed to be updated to reflect NASA and USA roles and responsibilities.

10. OIG Comment. This statement is not factual. USA was not complying with its own safety

procedures regarding the use and control of PFA’s. When we brought this noncompliance to the

attention of USA management during the audit, USA changed procedures concerning PFA's rather

than comply with established testing and safety assessment requirements.

USA safety and M&P personnel stated that they were unaware of any NASA requirement that

USA have all PFA’s tested for flammability resistance, ESD rate, and hypergolic compatibility prior

to general-purpose use in and around the orbiter vehicles. Those personnel told us that USA’s

position on PFA testing was that USA needed to test a PFA only for those hazards (flammability,

ESD rate, hypergolic compatibility) that could be reasonably expected based on the specific use of

each PFA. Furthermore, the USA M&P engineer specialist told us that he was unaware that the

GSOP 5400 required USA to perform all three tests on all PFA’s before use.
43

Appendix G

We subsequently met with USA safety and M&P personnel and gave them section 2.21 (pages 2-

50 through 2-52) of GSOP 5400, which states that all thin plastic films and adhesive tapes used in

the Space Transportation System (STS) and Payload areas must be approved by the Kennedy

Space Vehicle Safety and Reliability Divisions of the Kennedy Safety Office. In addition, Section

2.21 states that the use and approval of a thin plastic film or an adhesive tape “depends on the

results of its safety assessment. This assessment consists of tests which measure safety

characteristics.” Furthermore, Section 2.21 states, “Specific measurements are flammability,

electrostatic discharge rate, and hypergolic . . . compatibility.”

In response, the USA safety and M&P personnel stated that this particular section of GSOP 5400

could be confusing and could be interpreted incorrectly. The USA safety engineer stated that

before the Space Flight Operations Contract (SFOC) was signed, GSOP 5400 was a NASA

document and that, since USA had taken over ground operations of the Shuttle program, USA

management has gradually altered the document to suit its needs. Section 2.21 was one section of

the original NASA document that USA had yet to change to reflect its actual operating procedures.

USA would revise Section 2.21 to better reflect current operational procedures regarding use and

testing of PFA’s. However, during the audit, we found that USA quoted this section of GSOP

5400 in preparing a March 2000 safety variance for Lectrolite Duotone green/black film.

The USA safety engineer subsequently provided the revised sections of GSOP 5400 to the audit

team. The revised GSOP 5400 omitted the two sections that required risk assessments, including

tests of flammability resistance, ESD rate, and hypergolic compatibility, prior to using all plastic films

and adhesive tapes. USA’s rationale for the change stated only that, “Redlines are necessary to

clarify existing policies per NASA OIG audit.”

Management’s Comment. USA has the authority to change its “how to” policy documents

without NASA approval, as long as USA does not violate a higher level NASA safety requirement.

11. OIG Comment. This statement is not completely correct. According to Kennedy Shuttle

Safety Office officials, USA had the authority to change its “how to” policy documents without

NASA approval, as long as USA did not violate a higher level NASA safety requirement or

increase risk. In our opinion, omitting a requirement to perform risk assessments on PFA’s prior to

their use, including tests of flammability resistance, ESD rate, and hypergolic compatibility, increases

risk. USA should have promptly brought this change to the attention of the Kennedy Shuttle Safety

Office.

Management’s Comment. For PFA materials used in a hazardous environment, NASA safety

and mission assurance engineers are involved in the approval process.
44

Appendix G

12. OIG Comment. Our concern, as detailed in the report, is the method for making the

determination of hazardous use or whether a material is hazardous. We determined that only one

individual, the USA M&P engineer specialist (not a safety engineer), determined whether the

proposed use of the material posed a hazard. The M&P engineer did not seek

Kennedy or USA Safety Office involvement and did not submit the material to the Kennedy

Materials Science Lab for testing unless the engineer specialist determined that hazards were

present. In contrast, Kennedy Shuttle Safety office personnel stated that they believed (1) USA

submitted all Material Use Permits to the Kennedy Shuttle Safety Office for approval, no matter

how the materials were to be used, and that (2) at a minimum, USA had all new and previously

unapproved PFA’s tested for flammability resistance to establish whether the material itself may be

hazardous. In our opinion, and as reflected in this report, the Kennedy Shuttle Safety Office should

make the determination as to whether potential hazards are present in operations that involve

PFA’s.

Management’s Comment. Currently, NASA Shuttle M&P and Safety engineers perform

surveillance of procedures and task execution activities assessing the proper use of materials and the

implementation of safety requirements.

13. OIG Comment. In our opinion, the surveillance the NASA Shuttle M&P and Safety

engineers perform can be improved. Specifically, Kennedy Shuttle Safety Office personnel were

unaware that (1) the USA M&P engineer specialist frequently approved Material Use Permits

without consulting either the USA or Kennedy Shuttle Safety Offices, (2) USA did not have the

Kennedy Materials Science Lab test all PFA’s, and (3) USA made significant changes to its

materials safety procedures. Further, Kennedy Shuttle Safety Office personnel erroneously

believed that, at a minimum, USA tests all new, unapproved PFA’s for flammability resistance.

Management’s Comment. Kennedy and the Space Shuttle Program recognize NSTS 08242 as

the approved list of PFA’s approved for use in and around the orbiter vehicles.

14. OIG Comment. Management’s statement conflicts with the requirements referenced in the

SFOC. NSTS 08242 and the Kennedy Materials Science Lab often differ on whether a material is

approved for use in and around the orbiter. Although Kennedy stated that NSTS 08242 is the list

of PFA’s approved for use in and around the orbiter vehicles, that was not the case during the audit.

Specifically, we identified several, often conflicting, sources of approved materials and requirements

regarding material selection, testing, and control. For example, Appendix I of USA’s GSOP 5400

and Chapter 7 of the Kennedy Safety Practices Handbook state that current approved adhesive

tape and plastic film lists are on the Kennedy Materials Science Division Intranet. However, the

USA M&P engineer specialist also referred us to (1) Appendix C of NSTS 08242, (2) Material

Use Permit and safety variance files, and (3) MAPTIS when selecting PFA’s for use in
45

Appendix G

Kennedy's Space Shuttle processing facilities. As a result, there were at least five sources used for

identifying approved materials. On February 5, 2001, we presented this information to the

Kennedy Director of Shuttle Processing. When we subsequently met with the Kennedy Director of

Shuttle Processing on February 15, 2001, he was unable to identify a single approved list of PFA’s

approved for use in and around the orbiter vehicles. It was not until more that 4 months later that

management concluded that NSTS 08242 was the approved list of PFA’s approved for use in and

around the orbiter vehicles. Kennedy should approve one centralized source of materials for use in

and around the orbiter vehicles, with reference to all associated testing records to ensure that the

materials are used safely.

Management’s Comment. We recognize that gaining access to PFA materials evaluations and/or

test results performed at other NASA Centers is not always timely.

15. OIG Comment. Management’s statement is misleading. Of the 30 materials listed in

Appendix E of the report, testing records for 16 of the materials did not exist. Further, the testing

records that were available for the remaining 14 materials did not clearly show the results of the test.

Management’s Comment. When PFA material is proposed to be used and is not authorized by

NSTS 08242, a Material Usage Permit must be processed, and if the required test data cannot be

attained to support the Material Usage Permit assessment, the PFA material is sent to the Kennedy

Material Science Lab for required tests.

16. OIG Comment. Our audit work does not support management’s statement. The USA M&P

engineer specialist told us during the audit that PFA’s are tested only when he determines that

hazards may be expected in the use of the PFA. Furthermore, we identified at least one material

(RB0159-002 pressure sensitive tape) not authorized by NSTS 08242 for which no test records

existed. The USA M&P engineer specialist processed Material Use Permit 94-007, authorizing

permanent use of this material. The USA M&P engineer specialist approved the Material Use

Permit even though the Kennedy Materials Science Lab never tested the material. In addition, we

could not locate test records from any other NASA Center or test facility for this material.

Management’s Comment. Appendix E has been reviewed, and all 30 items were verified to be

authorized for use by NSTS 08242.

17. OIG Comment. There is no support for this statement because management has not

presented evidence of materials testing results for the materials from any NASA Center or test

facility.
46

Appendix H. Report Distribution

National Aeronautics and Space Administration (NASA) Headquarters

A/Administrator

AI/Associate Deputy Administrator

AA/Chief of Staff

AB/Associate Deputy Administrator for Institutions

B/Acting Chief Financial Officer

B/Comptroller

BF/Director, Financial Management Division

G/General Counsel

H/Associate Administrator for Procurement

HK/Director, Contract Management Division

HS/Director, Program Operations Division

J/Associate Administrator for Management Systems

JM/Director, Management Assessment Division

L/Acting Associate Administrator for Legislative Affairs

M/Associate Administrator for Space Flight

P/Associate Administrator for Public Affairs

Q/Associate Administrator for Safety and Mission Assurance

R/Associate Administrator for Aerospace Technology

S/Associate Administrator for Space Science

U/Acting Associate Administrator for Biological and Physical Science

X/Director, Office of Security Management and Safeguards

Y/Associate Administrator for Earth Science

Z/Acting Associate Administrator for Policy and Plans

NASA Advisory Officials

Chair, NASA Aerospace Safety Advisory Panel

NASA Centers

Director, Ames Research Center

Director, Dryden Flight Research Center

Director, John H. Glenn Research Center at Lewis Field

Director, Goddard Space Flight Center

Director, Jet Propulsion Laboratory

Chief Counsel, John F. Kennedy Space Center

Director, Langley Research Center

Director, George C. Marshall Space Flight Center
47

Appendix H

NASA Centers (Cont.)

Acting Director, John C. Stennis Space Center

Non-NASA Federal Organizations and Individuals

Assistant to the President for Science and Technology Policy

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

 Budget

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

 of Management and Budget

Director, Acquisition and Sourcing Management Team, General Accounting Office 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 and Oversight

House Subcommittee on Government Efficiency, Financial Management, and Intergovernmental

Relations

House Subcommittee on National Security, Veterans Affairs, and International Relations

House Subcommittee on Technology and Procurement Policy

House Committee on Science

House Subcommittee on Space and Aeronautics, Committee on Science

Congressional Member

Honorable Pete Sessions, U.S. House of Representatives
NASA Assistant Inspector General for Audits

Reader Survey

The NASA Office of Inspector General has a continuing interest in improving the usefulness of our

reports. We wish to make our reports responsive to our customers’ interests, consistent with our

statutory responsibility. Could you help us by completing our reader survey? For your

convenience, the questionnaire can be completed electronically through our homepage at

http://www.hq.nasa.gov/office/oig/hq/audits.html or can be mailed to the Acting Assistant Inspector

General for Audits; NASA Headquarters, Code W, Washington, DC 20546-0001.

Report Title: Controls Over the Use of Plastic Films, Foams, and Adhesive Tapes In and

Around the Space Shuttle Orbiter Vehicles

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Major Contributors to the Report

Kevin J. Carson, Deputy Assistant Inspector General for Audits

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