SEPTEMBER 24, 2007 

REVIEW REPORT

REPORT NO. IG-07-032 (ASSIGNMENT NO. S-06-011-00) 

OFFICE OF AUDITS

EFFECTIVE INSPECTION PROGRAM KEY TO 

IMPROVING LABORATORY SAFETY AT

GLENN RESEARCH CENTER

OFFICE OF INSPECTOR GENERAL

National Aeronautics and 

Space Administration 

 
REPORT NO. IG-07-032 

Final report released by: 

 signed 

Evelyn R. Klemstine 

Assistant Inspector General for Auditing 

Acronyms 

GLPD Glenn Lewis Policy Directive 

HAZCOM Hazard Communication Program 

OIG Office of Inspector General 

OSHA Occupational Safety and Health Administration 

PI Principal Investigator 

MSDS Material Safety Data Sheets 

SHED Safety, Health, and Environmental Division 

SOP Standard Operating Procedure 
SEPTEMBER 24, 2007 

REPORT NO. IG-07-032 

OVERVIEW

EFFECTIVE INSPECTION PROGRAM KEY TO IMPROVING 

LABORATORY SAFETY AT GLENN RESEARCH CENTER

The Issue 

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

Programs: one concerned laboratory safety and the review process for granting Glenn 

Research Center (Glenn) safety permits, and the second concerned the actions of “first 

responder” personnel to a January 2006 fire in a Glenn underground tunnel. This report 

addresses laboratory safety and the process for reviewing, approving, and maintaining 

safety permits for Glenn laboratory operations; a separate report will address the first 

responder’s activities as they relate to the emergency response system at Glenn. 

Glenn operates scientific laboratories that conduct research and development in areas 

such as microgravity science, fluid physics, and combustion science. To ensure that 

those laboratories are operated in accordance with applicable Federal, NASA, and Glenn 

safety guidance, Glenn requires that each of the laboratories apply for and maintain a 

safety permit that gives the authority to operate a laboratory or piece of equipment within 

the constraints listed on the permit. In addition, the Safety, Health, and Environmental 

Division (SHED) of Glenn’s Safety and Mission Assurance Directorate manages a safety 

and health inspection program with inspectors responsible for detecting, and reporting 

on, hazardous conditions, unsafe work practices, and other occupational safety and health 

issues identified in the laboratories. 

We reviewed the management of the safety permit system and the safety and health 

inspection program, specifically focusing on their impact on overall laboratory safety. In 

January 2007, we conducted a review of 22 Glenn laboratories and evaluated the 

laboratory conditions and operations against Glenn’s laboratory safety guidance and the 

constraints listed on the laboratory safety permit. We also compared the results of our 

review to laboratory inspections performed as part of the safety and health inspection 

program. The details of our review’s scope and methodology are in Appendix A. 
OVERVIEW

ii REPORT NO. IG-07-032 

Results 

Glenn did not ensure that all of its laboratories were operated in compliance with Glenn 

safety guidance. Specifically, we identified incidents of noncompliance in each of the 

22 laboratories that we reviewed. For those 22 laboratories,1

• 9 did not have a safety permit, the safety permit had expired, or the safety permit 

remained active after laboratory operations had ceased; 

• 10 did not have a current or approved standard operating procedure (SOP) (7 had 

no SOP, 2 had SOPs that had expired, and 1 had an SOP that lacked the required 

signature/approval of the Glenn Chemical Hygiene Officer); 

• 16 did not properly identify and store hazardous chemicals or maintain the 

required information for their safe use (for example, in 14 of the 18 laboratories, 

we found unattended flammable chemicals that were not properly stored); 

• 17 were operated without adequate engineering controls or safeguards2

 (for 

example, in 1 laboratory, water valves used to control chilled water were located 

directly above electrically energized equipment, where inadvertent leaks or a line 

rupture could cause an electrically initiated fire and/or result in serious electrical 

shock); 

• 7 were not maintained clean and free from potential hazards, such as keeping 

aisles and stairways free from clutter, cleaning chemical spills, minimizing 

combustibles in workplace and storage areas, and keeping all exits free from 

obstructions; 

• 7 were operated by personnel without the requisite safety training, to include 

laboratory management personnel; and 

• 13 did not meet fire and life safety standards (for example, laboratory personnel, 

when queried, did not have knowledge of primary and secondary emergency 

evacuation routes, did not know the location of the designated safe area, and were 

unfamiliar with the location of the nearest fire alarm). 

Because SHED relies on the facility safety and health inspection program to detect 

laboratory safety violations, we analyzed the SHED inspection results from laboratory 

inspections conducted on or about the period of our review. That analysis indicated that 

 

1

 The initial sample selected for inspection totaled 39 laboratories, however due to on-going hazardous 

operations, locked doors, and/or the unavailability of laboratory personnel, we were only able to inspect 

22 of the laboratories. 

2

 Engineering controls eliminate or reduce exposure to a chemical or physical hazard through the use or 

substitution of engineered machinery or equipment. 
OVERVIEW

REPORT NO. IG-07-032 iii 

the SHED inspectors did not identify all of the issues that we identified during our 

review. However, it was difficult to fully validate that premise because SHED did not 

require its inspectors to identify all of the laboratories included in a specific inspection, 

only those laboratories that had violations. Therefore, we did not know whether the 

inspectors missed some of the problems we found or whether some of the problems we 

found were in laboratories that were not included in their inspection. 

The inspection program’s effectiveness could be improved if all laboratories at Glenn 

were subjected to inspection through inclusion in the inspection universe. SHED had 

defined its inspection universe as only those laboratories that had active safety permits, 

which did not account for those laboratories that may have never applied for a permit or 

whose safety permit had expired. We compared the SHED laboratory list to a list 

contained in the Glenn Facilities Division database and noted that the Facilities Division 

database included 192 more laboratories than the SHED list. Although both lists could 

be partially incorrect, reconciliation should be performed periodically to ensure that 

SHED maintains a comprehensive laboratory universe. 

The effectiveness of the inspection program is also dependent on adequate follow up of 

the violations identified during the laboratory inspections. Although Glenn safety 

guidance required that corrective action plans be prepared for safety violations remaining 

open after 30 days, we identified 87 violations that should have had plans but did not. 

Nine of those violations were considered as having the potential to cause minor or severe 

injury or damage to personnel or equipment. 

The risk of injury and/or damage associated with Glenn laboratory operations increases 

when those operations are not conducted in compliance with Glenn safety guidance. 

According to NASA’s Incident Reporting Information System, during the 17-month 

period from January 2006 through May 2007, Glenn reported 28 mishaps3

 and close 

calls4 that were directly or indirectly related to laboratory operations and the types of 

noncompliance issues that we identified. Had Glenn’s facility safety and health 

inspection program been more effective in identifying, tracking, and monitoring 

laboratory safety violations, we expect that we would have identified fewer incidents of 

safety noncompliance. Improving the effectiveness of the inspection program should 

improve safety compliance and, most important, should reduce the risk of injury to 

personnel and damage to assets and facilities resulting from laboratory operations. 

 

3

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

NASA categorizes mishaps as Type A through Type D based on the severity of injury to personnel or 

total cost of damage to property. 

4

 NASA defines a close call as an occurrence or employee concern that did not result in injury to personnel 

or significant damage to property but possesses the potential to cause a mishap. 
OVERVIEW

iv REPORT NO. IG-07-032 

Management Action 

Subsequent to our laboratory review, Glenn began taking corrective action to address a 

number of issues that are identified in this report. Specifically, SHED has initiated a 

comprehensive review of the Glenn chemical management and laboratory safety 

programs and initiated an update of chemical inventories by use of a commercially 

available database. For our findings that indicated an immediate health and/or safety 

threat, such as the improper storage of chemicals, SHED instituted a stop-work order and 

effectively mitigated the threat. That action, along with corrective action taken in 

response to our recommendations, should continue to improve the safety posture within 

the Glenn laboratories. 

In a draft of this report, we recommended that the Director, Safety and Mission 

Assurance, Glenn Research Center, ensure that SHED develops a process that will 

comprehensively define the laboratory universe for the facility safety and health 

inspections. We also recommend that the Glenn Safety Manual, Chapter 24, be revised 

to require the facility safety and health inspectors to indicate not only the building 

number in which an inspection took place, but also the specific laboratories that were 

inspected. We recommend that Chapter 24 be further revised to require that the safety 

and health violation database be monitored and that Glenn management be notified of all 

past-due violations and corrective action plans. Finally, we recommend that SHED 

coordinate a safety stand-down day, in which laboratory personnel conduct a safety selfassessment of their laboratories and that the results of those assessments be used by 

SHED to issue violation notices and identify any systemic safety issues. 

The Director, Glenn Research Center concurred with our finding and recommendations 

and provided a corrective action plan that details the actions to be taken for each 

recommendation along with planned completion dates (see Appendix E). We consider 

the recommendations resolved and will close the recommendations upon completion and 

verification of management’s corrective actions. 
SEPTEMBER 24, 2007 

REPORT NO. IG-07-032 

CONTENTS

INTRODUCTION

Background __________________________________________ 1 

Objectives ___________________________________________ 2 

RESULTS

Safety Guidance Not Always Followed at Glenn Laboratories ____ 4 

APPENDIX A 

Scope and Methodology _______________________________ 15 

Review of Internal Controls _____________________________ 16 

Prior Coverage_______________________________________ 16 

APPENDIX B 

OIG Review Results ___________________________________ 17 

APPENDIX C 

Basic Inspection Checklist ______________________________ 29 

APPENDIX D 

Detailed Inspection Checklist ___________________________ 32 

APPENDIX E 

Management Comments _______________________________ 41 

APPENDIX F 

Report Distribution ___________________________________ 49 

SEPTEMBER 24, 2007 

REPORT NO. IG-07-032 1 

INTRODUCTION

Background 

As one of NASA’s 10 Centers, the Glenn Research Center (Glenn) develops and transfers 

critical technologies that address national priorities through research, technology 

development, and systems development for safe and reliable aeronautics, aerospace, and 

space applications. To accomplish its mission, Glenn operates scientific laboratories 

where research and development is conducted in areas such as microgravity science, fluid 

physics, and combustion science. The laboratories play a key role in aeropropulsion and 

turbomachinery and are major contributors in material science, aircraft and spacecraft 

structures, instrumentation and controls, and aircraft icing research. According to the 

Glenn Facilities Division, there are 563 laboratories located at Glenn’s Lewis Field, 

which is adjacent to Cleveland Hopkins International Airport in Ohio. 

Laboratory Management. The Glenn laboratories are managed by a principal 

investigator5 (PI) for the research or technology project or projects that are ongoing in a 

specific laboratory. At Glenn, laboratory personnel work for three of the four NASA 

Mission Directorates—Aeronautics Research, Exploration Systems, and Science. 

Although the laboratories are managed and operated by personnel who work for NASA’s 

Mission Directorates, the authority to conduct a research or technology project in a 

specific laboratory is granted through the Glenn safety permit system. An approved 

safety permit constitutes a license to operate a laboratory or piece of equipment within 

the constraints listed on the permit. 

Laboratory Safety. Glenn’s Safety, Health, and Environmental Board is responsible for 

safety, health, and environmental policy and decision making and provides management 

leadership and oversight for the Center’s Safety and Health Management System. The 

Center Director chairs the Board, and members include the Glenn Operational Directors, 

the Director of Safety and Mission Assurance, and Glenn’s Chief Counsel. The Safety, 

Health, and Environmental Division (SHED) of Glenn’s Safety and Mission Assurance 

Directorate is responsible for laboratory safety and the safety permit system. SHED is 

comprised of three Branches—Safety, Occupational Health, and Environmental 

Management. The Safety Branch recommends minimum acceptable safety standards for 

Center operations, maintains illness and injury records, and monitors Center activities to 

ensure compliance with all applicable safety standards and regulations. The 

Occupational Health Branch is responsible for the evaluation and measurement of 

exposure hazards in the work environment that can cause long-term or latent illness and 

 

5

 NASA Procedural Requirements 1080.1, “NASA Science Policy,” February 2, 2005, defines Principal 

Investigators as “scientists external or internal to NASA who have received funding to perform specific 

research tasks.” 
INTRODUCTION

2 REPORT NO. IG-07-032 

disease. The Environmental Management Branch identifies risks posed by current and 

past Glenn programs, operations, and activities and develops and implements processes 

to remediate, abate, and control those risks. 

The Safety, Health, and Environmental Board delegated the approval process for the 

safety permit system to 14 Area Safety Committees (9 geographically based and 

5 specialty based). The Area Safety Committees are comprised of a chairperson, 

personnel with engineering and operational expertise, and representatives from SHED, as 

needed. The Area Safety Committees review proposals for all research and development 

operations, for modifications or additions to facilities and equipment, and for any project 

that may affect safety within their assigned safety area. For those proposals that meet 

Glenn safety requirements, the Committee approves and issues a safety permit; once the 

permit is issued, the requestor may begin the research operation or experiment. SHED’s 

Safety Branch is responsible for maintaining a list of the issued permits and conducting 

periodic inspections of the laboratories to identify hazardous conditions, unsafe or 

unhealthy work practices, and other safety and health issues. The PI must submit a 

revision to the safety permit upon any deviation from the procedures or requirements 

listed on the permit. 

Glenn Safety Guidance. Glenn’s overarching safety policy is Glenn Lewis Policy 

Directive (GLPD) 1702.1I, “Glenn Safety and Health Program,” April 2005, which 

parallels NASA Policy Directive 8710.2D, “NASA Safety and Health Program Policy,” 

April 28, 2004. GLPD 1702.1I addresses the need to effectively manage operations so 

that risk to personnel, property, and the environment is eliminated or reduced. Policy 

documents for other aspects of the safety program include GLPD 1800.2, “Glenn 

Research Center Occupational Health Program,” September 2006, and GLPD 8500.1, 

“NASA Glenn Environmental Management System,” April 2007. The three SHED 

branches publish implementation instructions for Glenn safety guidance in three 

manuals—the Glenn Safety Manual, the Occupational Health Programs Manual, and the 

Environmental Programs Manual. 

Objectives 

Our overall objective was to determine whether the Glenn Safety Program was operated 

in accordance with applicable Federal, NASA, and Glenn guidance and if appropriate 

steps were being taken to prevent injury to Center personnel and damage to NASA 

assets. The review was initiated in response to two hotline complaints concerning Glenn 

Safety Programs: the first concerned laboratory safety and the review process for 

granting Glenn safety permits and the second concerned the actions of “first responder” 

personnel to a January 2006 fire in a Glenn underground tunnel. This report addresses 

laboratory safety and the process for reviewing, approving, and maintaining safety 

permits for Glenn laboratory operations; a separate report will address the first 

responder’s activities as they relate to emergency response at Glenn. We also reviewed 

internal controls as they related to the review objective. See Appendix A for details of 
INTRODUCTION

REPORT NO. IG-07-032 3 

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

coverage. 
RESULTS

4 REPORT NO. IG-07-032 

SAFETY GUIDANCE NOT ALWAYS 

FOLLOWED AT GLENN 

LABORATORIES

Glenn did not ensure that all of its laboratories were operated in compliance with 

Glenn safety guidance. Specifically, we identified incidents of noncompliance in 

each of the 22 laboratories that we reviewed. For those 22 laboratories,6

• 9 did not have a safety permit, the safety permit had expired, or the safety 

permit remained active after laboratory operations had ceased; 

• 10 did not have a current or approved standard operating procedure; 

• 16 did not properly identify and store hazardous chemicals or maintain the 

required information for their safe use; 

• 17 were operated without adequate engineering controls or safeguards7

; 

• 7 were not maintained clean and free from potential hazards; 

• 7 were operated by personnel without the requisite safety training; and 

• 13 did not meet fire and life safety standards. 

SHED’s facility safety and health inspection program was not effectively 

accomplishing its mission to ensure that laboratory safety violations were identified 

and adequately corrected. As a result, Glenn personnel, assets, and facilities were 

placed at an increased risk of injury and/or damage associated with laboratory 

operations. Review of NASA’s Incident Reporting Information System for the 

17-month period from January 2006 through May 2007 indicates that 28 of the 

247 mishaps and close calls reported at Glenn were directly or indirectly related to 

laboratory operations and the types of noncompliance issues that we identified. 

Laboratory Safety Guidance 

The “Glenn Safety Manual,” April 2007, and the “Environmental Programs Manual,” 

April 2007, provide specific safety guidance for the Glenn laboratories. The manuals 

 

6

 The initial sample selected for inspection totaled 39 laboratories, however due to on-going hazardous 

operations, locked doors, and/or the unavailability of laboratory personnel, we were only able to inspect 

22 of the laboratories. 

7

 Engineering controls eliminate or reduce exposure to a chemical or physical hazard through the use or 

substitution of engineered machinery or equipment. 
RESULTS

REPORT NO. IG-07-032 5 

contain instruction concerning the safety permit system, laboratory standard operating 

procedures (SOP), hazardous chemicals, engineering controls, employee training, and 

fire protection. 

Glenn Safety Manual. The Glenn Safety Manual contains the requirements for safety 

permits and inspections, engineering controls, and fire protection. Chapter 1A, “Safety 

Permit System,” identifies certain activities likely to require an approved safety permit 

and outlines the procedures for requesting, reviewing, issuing, maintaining, renewing, 

and terminating safety permits. Chapter 15, “Personal Protective Equipment,” discusses 

requirements for identifying relevant engineering controls and the need for personal 

protective equipment such as ventilation and respiratory protection. Chapter 27 

“Building Emergency Evacuation Plan Program,” and Chapter 31, “Fire Protection,” 

discuss the fire and life safety protective measures necessary to ensure safe and orderly 

emergency evacuations and the requisite controls designed to prevent, contain, and 

mitigate fires. 

Environmental Programs Manual. The Environmental Programs Manual contains the 

requirements for the Hazard Communication (HAZCOM) Program. The purpose of the 

HAZCOM Program is to inform employees of the hazards associated with chemicals in 

the workplace. Chapter 16, “Hazard Communication Policy,” establishes the methods for 

communicating chemical hazard information, which includes container labeling, Material 

Safety Data Sheets (MSDS),8 and employee training. The Environmental Programs 

Manual also contains the requirements for laboratory SOPs, chemical management, 

laboratory maintenance, and training. Chapter 17, “Chemical Hygiene Policy,” requires 

every Glenn laboratory to develop an SOP describing the specific operations that take 

place in the laboratory. Each laboratory SOP, along with general measures established in 

the Chemical Hygiene Plan, defines the requisite engineering and procedural controls 

designed to protect employees from the harmful affects of chemicals used in a laboratory. 

Chapter 17 also contains a list of general training requirements for those laboratory 

employees that work with or around hazardous chemicals. 

Laboratory Reviews Identified Noncompliance Issues 

Glenn did not ensure that all of its laboratories were operated in compliance with Glenn 

safety guidance. We identified a total of 150 incidents of noncompliance in the 

22 laboratories that we reviewed, pertaining to safety permits, SOPs, chemical 

management, laboratory safeguards, laboratory maintenance, and training. (See 

Appendix B for the list of noncompliance incidents.) 

 

8

 The Occupational Safety and Health Administration (OSHA) requires chemical manufactures to develop 

MSDS to inform end-users of a chemical’s composition, physical hazards, health hazards, exposure 

routes and limits, toxicology, instructions for safe use, emergency and first aid procedures, and the 

manufacture’s contact information. 
RESULTS

6 REPORT NO. IG-07-032 

Figure 1. Corrosion in laboratory sink.

Safety Permits. Safety permits were not available or valid in nine of the laboratories. In 

eight of the laboratories, operations were taking place that required a safety permit but 

the PI could not provide one. For example, in the Shape Memory Alloy Research and 

Technical Laboratory, laboratory personnel were working with a laser and other highvoltage equipment; however, there was no safety permit posted. According to Chapter 

1A of the Glenn Safety Manual, any operation or activity that uses hazardous chemicals, 

pressurized systems, lasers, electrical or mechanical energy sources, or otherwise 

requires fire and life safety controls must have a safety permit. 

The ninth laboratory had an active safety permit posted on the laboratory door, but 

according to documentation gathered in the laboratory, operations had been terminated 

for months. We were able to gain unrestricted access to the laboratory where we 

observed unlabeled chemical containers on top of a workbench and flammable chemicals 

that were improperly stored in a cabinet that was not 

rated for flammable chemical storage. We also 

observed glassware that was coated with a crystallized 

residue and syringes, sharps, and test equipment that 

was unsecured. The laboratory sink contained 

unidentified corrosion and discoloration that is 

consistent with improper waste disposal (see 

Figure 1). None of these conditions should have 

existed, as the Safety Manual specifically states that 

when a laboratory operation or activity is terminated, 

the PI should remove and return the safety permit to 

the Glenn Safety Branch and coordinate the phase out 

of the operation, including the removal and disposal of all hazardous materials. 

Laboratory SOPs. Laboratory SOPs were not available or were incomplete in 10 of the 

laboratories. Specifically, 7 laboratories had no SOP and 2 had SOPs that had expired; 

one SOP lacked the required signature/approval of the Glenn Chemical Hygiene Officer. 

The Environmental Programs Manual, Chapter 17, establishes the Glenn Chemical 

Hygiene Plan, which requires the laboratory PIs to develop and submit an SOP to the 

Chemical Hygiene Officer if the PI plans to use chemicals in conducting his or her 

research. The SOP must include an overview of laboratory operations, identify the 

chemicals the PI plans to use in the laboratory, list the regulatory compliance 

requirements, describe emergency response procedures, and reflect guidance for revising 

the SOP, if needed. Without an SOP, laboratory personnel and personnel responding to a 

laboratory emergency may not have access to detailed safety and health information 

tailored to that specific laboratory. 

Chemical Management. With regard to chemical management, we identified 

noncompliance issues in 16 of the laboratories. The Chemical Hygiene Plan outlines the 

Center’s policy regarding chemical management and, in conjunction with the laboratory 

SOPs, contains procedural and engineering controls designed to protect laboratory 

workers from harmful affects presented by hazardous chemicals. The majority of the 
RESULTS

REPORT NO. IG-07-032 7 

Figure 2. Unattended and unlabeled containers 

holding hazardous chemicals. 

noncompliance issues that we identified concerned improper chemical storage and 

labeling. In 14 laboratories, we found unattended flammable chemicals that were not 

properly stored. The Chemical Hygiene Plan requires that all flammable chemicals be 

stored in an approved flammable storage cabinet.9 It also requires that incompatible 

chemicals or chemicals that can react violently, generate substantial heat, or produce 

flammable or toxic by-products, be segregated from one another. In one laboratory, we 

discovered highly hazardous and reactive chemicals (bromine and lithium) co-located in 

the same unmarked storage space.10 We also observed instances where food and 

beverages were consumed in areas where chemicals were used and stored. 

Regarding chemical labeling, we found unlabeled 

hazardous chemicals in six of the laboratories (see 

Figure 2). The Chemical Hygiene Plan requires all 

hazardous chemicals to be properly labeled in 

accordance with the HAZCOM Program. The 

label must match the information as stated on the 

MSDS. The labels should list the name of the 

chemical, hazard warnings, and the name and 

address of the manufacturer or other responsible 

party. Containers labeled by the chemical 

manufacture do not require additional labels; 

however, when chemicals are transferred to other containers (secondary containers), 

these secondary containers must be separately labeled.11

The HAZCOM Program also requires that the employees have ready access to the MSDS 

and that an inventory be maintained for all hazardous chemicals used and stored in the 

workplace. We found that in seven laboratories, personnel did not have ready access to 

the MSDS and were unfamiliar with the properties and hazards of the chemicals used and 

stored in the laboratories. In three of the laboratories, personnel stated that they 

maintained MSDS for the laboratory on an automated information system; however, in 

each instance; computer terminals were not located in the laboratories. According to the 

HAZCOM Program, where electronic access is not available, laboratories should 

maintain the MSDS as hardcopy (i.e., provided as a paper document). 

 

9

 In accordance with the National Fire Protection Association’s “Flammable and Combustible Liquids 

Code,” Chapter 4.3.3 (b), and OSHA 29, Code of Federal Regulations 1910.106 (d)(3)(ii)(a), an 

approved flammable chemical storage cabinet is constructed of doubled walled No. 18 gauge sheet steel 

with 1 1⁄2 in. (3.8 cm) of air space. The door must have a 3-point latching arrangement and the doorsill 

raised at least 2 in. (5 cm) above the bottom of the cabinet to retain spilled liquid. 

10 Bromine is a highly reactive corrosive that poses a serious health threat. Although classified as a 

noncombustible material, bromine will act as an accelerant and react violently when it is exposed to 

combustible materials. Lithium is a combustible solid that may ignite or explode when it is exposed to 

flame, heat, corrosives, or oxidizers. 

11 The only exception to this requirement is if the chemical is intended for immediate use; however, none 

of the instances we are reporting involved chemicals intended for immediate use. 
RESULTS

8 REPORT NO. IG-07-032 

Figure 3. Water valves piped over energized 

electrical equipment. 

Figure 4. Water intrusion around electrically 

energized equipment. 

Lastly, in five of the laboratories, the chemical inventory list did not reflect the chemicals 

in use and stored in the laboratory. One of those lists had not been updated since 

April 11, 1991. The Chemical Hygiene Plan requires that chemical inventories be taken 

at least annually. 

Laboratory Safeguards. With regard to 

laboratory safeguards, 17 of the laboratories did 

not have engineering controls in place that were 

commensurate with all recognized laboratory 

hazards. For example, in one of the laboratories, 

the PI was performing tests and conducting 

research into the magnetization of neodymiumiron-boron (NdFeB). In order to magnetize this 

material, the PI used a wide variety of electrically 

energized support equipment. Although the 

engineering design was effective to support the 

technical process, basic safety considerations were not incorporated into the design. For 

example, water used to chill the equipment was piped directly over the energized 

equipment where a leak or rupture could result in an electrically initiated fire and/or 

cause electrical shock. The design also included in-line gate valves and fittings that 

could fail or leak, further reducing the margin of safety (see Figure 3). In another 

instance, laboratory personnel were working with a laser without requisite personal 

protective equipment,12 such as protective eye wear. The Safety Manual requires 

laboratory supervisors and SHED to perform hazard assessments for each laboratory to 

identify hazards and to institute engineering controls and protective equipment to 

mitigate recognized hazards. 

Laboratory Maintenance. In seven laboratories, 

laboratory maintenance standards were not being 

met. The Safety Manual states that all personnel 

are responsible for laboratory safety and must 

follow housekeeping guidelines such as keeping 

aisles and stairways free from clutter, cleaning 

chemical spills, minimizing combustibles in 

workplace and storage areas, and keeping all exits 

free from obstructions. In the NdFeB laboratory, 

we found evidence of water intrusion around 

electrically energized laboratory equipment and 

along one of the laboratory walls, which created an electric shock hazard and a slip 

hazard (see Figure 4). In the other six laboratories, we found needles, syringes, and 

hazardous tools left out in unoccupied work areas and “slip, trip, and fall” types of 

hazards due to debris accumulation on laboratory floors.

 

12 Personal protective equipment comprises clothing, devices, and other accessories designed to create a 

barrier against workplace hazards. The equipment can include safety glasses, hard hats, safety shoes, 

gloves, ear protection, respirators, and other protective items. 
RESULTS

REPORT NO. IG-07-032 9 

Figure 5. Blocked path of emergency egress. 

Training. Personnel in seven of the laboratories did not have training commensurate 

with the work being performed in the laboratory. In several of those laboratories, 

personnel were working with hazardous chemicals and/or biological agents. For 

example, in the “Vertebrate Cell Culture Laboratory,” laboratory personnel were working 

with quail eggs to study biological phenomena such as blood vessel and bone cell 

development; however, the laboratory’s PI stated that she did not have the required 

HAZCOM training. The HAZCOM Program requires laboratory personnel to attend 

HAZCOM training at least once every 3 years. HAZCOM training includes instruction 

on HAZCOM standards, MSDS, Glenn safety policies and procedures, chemical 

inventories, and provides contact information for the Safety Branch. 

Fire and Life Safety. We identified 13 

laboratories that were noncompliant with the 

Safety Manual’s fire and life safety 

requirements with regard to emergency egress, 

emergency response, and hazardous waste 

disposal. The Safety Manual defines 

emergency egress as the process by which a 

continuous and unobstructed way of exit travel 

is maintained from any point in a building to a 

predetermined safe location. We observed 

corridors and a stairway that were identified as 

exit routes but were obstructed by boxes and 

unused equipment (see Figure 5). We also 

noted one instance in which exit signs led personnel to a locked exit door. 

With regard to emergency response, personnel in five of the laboratories stated that they 

were unsure of their responsibilities during a fire emergency or chemical spill or release. 

Other personnel stated that they were unsure as to how or when to use a portable fire 

extinguisher. In two of the laboratories, access to the fire extinguishers was partially 

blocked by crates, boxes, and laboratory equipment. The Safety Manual states that 

individual employees are required to be familiar with the emergency procedures for their 

particular work area. Familiarity includes having knowledge of the primary and 

secondary emergency evacuation route, the location of the designated safe area, and the 

identity of the building evacuation monitors. In the event of a fire, personnel are required 

to know the location of the nearest alarm and how to report the emergency to the Glenn 

dispatcher and, if qualified, to fight a fire in its beginning stages by using the appropriate 

portable fire extinguisher. 

Finally, in the area of combustible waste, we identified such waste accumulated on 

workbenches and improperly deposited into ordinary trash receptacles. For the 

laboratories that were using the proper hazardous waste receptacles, those receptacles 
RESULTS

10 REPORT NO. IG-07-032 

were not emptied on a daily basis. OSHA regulations13 require combustible waste to be 

discarded in covered, self-closing receptacles and that those receptacles be emptied daily. 

Safety and Health Inspection Program 

SHED’s facility safety and health inspection program was not effectively accomplishing 

its mission to ensure that laboratory safety violations were identified and adequately 

corrected. 

Inspection Program. SHED relies on safety and health inspections as the principal

means to detect hazardous conditions, unsafe work practices, and other occupational 

safety and health issues in its laboratories. The Glenn Safety Manual, Chapter 24, 

“Facility Safety and Health Inspection Program,” identifies the types of facility safety 

and health inspections SHED conducts, the frequency of those inspections, and the 

responsibilities of the inspectors, management, and the Glenn Safety Branch. SHED 

performs two types of inspections—basic and detailed. Basic inspections are 

unscheduled inspections performed to identify fire, life safety, and industrial hygiene14

violations. Detailed inspections cover four areas—safety and health, chemical 

management, industrial hygiene, and health physics—and are designed to identify safety 

violations such as expired safety permits. Basic inspections are performed by Safety 

Branch representatives on a bimonthly basis and detailed inspections are scheduled 

inspections conducted by a team led by a Safety Branch representative. Depending on 

the criticality and risk15 associated with each facility, detailed facility safety and health 

inspections are performed on a quarterly or annual basis. 

The inspectors use the SHED-developed Bi-Monthly Facility Inspection Checklist when 

performing basic inspections and the Facility Safety and Health Inspection Checklist 

when performing detailed inspections (see Appendixes C and D for copies of the 

checklists). SHED maintains a database that tracks the violations recorded on the 

checklists, generates violation notices, and provides management reports. When a 

violation is posted to the database, a safety violation notice is generated and distributed to 

the PI’s chain of command and the respective building manager where the violation 

occurred. For violations that are open for 30 days or longer, the Safety Manual requires 

that the PI develop a corrective action plan, which must contain a justification as to why 

the violation remains unresolved, a description of the planned corrective action, 

timeframes for completing corrective action, and interim actions to protect employees 

from unsafe conditions caused by the violation. 

 

13 In accordance with OSHA 29, Code of Federal Regulations 1910.106(h)(8)(iii), combustible waste 

material and residue must be kept to a minimum; stored in closed, metal waste cans; and disposed of 

daily. 

14 Industrial hygiene is defined as a science devoted to the protection and improvement of the health and 

well-being of workers exposed to chemical and physical agents in their work environment. 

15 “Risk” is characterized in the Glenn Safety Program by combining the probability that an undesired 

event will occur with the consequences or severity if it were to occur. 
RESULTS

REPORT NO. IG-07-032 11 

Laboratory Inspection Universe. SHED did not include all Glenn laboratories in its 

inspection universe and was not aware of the total number of facilities that were 

designated as laboratories at Glenn. When we attempted to define the universe of Glenn 

laboratories for our review, we requested that SHED provide us a list of all Glenn 

laboratories that were conducting operations that warranted inspection under the facility 

safety and health inspection program. SHED personnel stated that their inspection 

universe was based on a list of laboratories with active safety permits and provided a list 

containing 371 laboratories. Upon receiving the list, we became concerned that limiting 

the inspections to laboratories with “active” safety permits did not account for those 

laboratories that had not applied for a permit but should have or those laboratories whose 

safety permits had expired. Subsequently, we contacted the Glenn Facilities Division and 

requested a list of Glenn laboratories from its database. We received a list of 

563 laboratories from the Facilities Division database; 192 laboratories more than the 

SHED list. Neither SHED nor the Facilities Division was aware that such a difference in 

the number of laboratories existed, and we could not confirm whether reconciliation 

between the two lists had ever been conducted. 

SHED needs to include all laboratories in its inspection universe. In our review of 

22 laboratories, we identified 9 laboratories that had no safety permit or had an expired 

safety permit and, therefore, would not be included in the SHED universe. Each of those 

laboratories was conducting operations that required a safety permit and commensurate 

safety controls. To ensure that SHED has visibility over each of the Glenn laboratories, 

it needs to periodically reconcile its list of laboratories that have active safety permits 

with the Facilities Division database. This will improve SHED’s ability to maintain a 

comprehensive inspection universe and identify those laboratories that may be operating 

in violation of Safety Manual requirements and without the proper safety controls. 

Identification of Laboratories Inspected. The inspectors were not required to complete 

checklists for each laboratory inspected during the basic or detailed safety inspections. 

Because we identified 22 laboratories with 150 instances of noncompliance, we wanted 

to determine whether the results of the SHED basic and detailed inspections conducted 

around the period of our review contained similar findings. Because we conducted our 

laboratory review in January 2007, we requested all SHED inspection checklists for the 

period December 2006 through March 2007. Upon review, we found that only the 

laboratories in which violations were identified were annotated on the checklist; the 

checklist did not contain a list of all laboratories inspected. Therefore, we were unable to 

perform a laboratory-by-laboratory comparison between our results and the SHED 

inspection results, although according to the checklists, the SHED inspectors found only 

five health and safety violations in the buildings that we reviewed. Not requiring the 

inspectors to identify all laboratories inspected makes it difficult to hold the inspectors 

accountable for the inspection results because there is no evidence showing which 

laboratories were actually inspected and which laboratories may have been locked or 

otherwise inaccessible during the inspection. 
RESULTS

12 REPORT NO. IG-07-032 

Inspection Follow-Up. SHED did not adequately follow up on all laboratory safety 

violations identified during the basic and detailed inspections. We reviewed safety 

violation notices issued for the 17-month period between January 2006 and May 2007. 

During that period, SHED issued 165 safety violation notices against the laboratory 

buildings that we reviewed, of which 99 violations remained open for 30 days or longer. 

According to the Glenn Safety Manual, a corrective action plan should be prepared for 

any violation remaining open for more than 30 days. However, only 12 of the 99 open 

violations had corrective action plans. For the 87 violations that did not have corrective 

action plans, 9 were classified as Code 3 or Code 2 violations. Code 3 violations have 

the potential of causing minor injury or damage to personnel or equipment; Code 2 

violations have the potential of causing severe injury or damage to personnel or 

equipment. Glenn should not have those type of violations open for extended periods, 

without a valid corrective action plan. The Safety Manual properly addresses the issue 

by requiring that corrective action plans be prepared and justifications be given as to why 

the violation remains open; however, SHED needs to periodically monitor its violation 

database and ensure corrective action plans are developed for all past-due safety 

violations. Special attention should be given to those violations that are Code 3 or higher 

to ensure that appropriate action is taken to keep employees and equipment safe. 

Associated Risk 

The risk of injury and/or damage associated with Glenn laboratory operations increases 

when those operations are not conducted in compliance with Glenn safety guidance. In 

our review of 22 laboratories, we identified 150 instances in which that safety guidance 

was not properly followed. Because we did not derive our sample statistically, we cannot 

project our results to the entire universe of Glenn laboratories; however, we believe that 

our results provide a solid indication that improvements are warranted. According to 

NASA’s Incident Reporting Information System, during the 17-month period from 

January 2006 through May 2007, Glenn reported 247 mishaps16 and close calls17 and 

sustained more than $449,049 in related property and vehicle damage. Of those mishaps 

and close calls, 28 directly or indirectly related to laboratory operations and the types of 

noncompliance issues that we identified. Had Glenn’s facility safety and health 

inspection program been more effective in identifying, tracking, and monitoring 

laboratory safety violations, we expect that we would have identified fewer incidents of 

safety noncompliance. Because we reviewed only 22 of the 563 Glenn laboratories 

(4 percent), we believe that SHED should coordinate and sponsor a laboratory standdown day, in which the PI and his or her staff could conduct a safety self-assessment 

based on the SHED checklists. This would provide SHED a baseline of laboratory 

 

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

NASA categorizes mishaps as Type A through Type D based on the severity of injury to personnel or 

total cost of damage to property. 

17 NASA defines a close call as an occurrence or employee concern that did not result in injury to 

personnel or significant damage to property but possesses the potential to cause a mishap. 
RESULTS

REPORT NO. IG-07-032 13 

conditions, allow for the identification of systemic issues that may need to be addressed 

Center-wide, and provide a universe for follow-up inspections. Such an effort, along 

with improving the effectiveness of the inspection program should improve safety 

compliance, and most important, should reduce the risk of injury to personnel and 

damage to assets and facilities resulting from laboratory operations. 

Management Actions 

Subsequent to our laboratory review, Glenn began taking corrective action to address the 

150 noncompliance incidents that we identified. To facilitate that action, we briefed 

senior Glenn management and the SHED chief of our laboratory review results. Both 

were very receptive to our findings. The SHED chief has since initiated a comprehensive 

review of the Glenn chemical management and laboratory safety programs. SHED has 

also begun updating the chemical inventories by use of a commercially available 

database. For our findings that indicated an immediate health and/or safety threat, such 

as the improper storage of chemicals, SHED instituted a stop-work order and effectively 

mitigated the threat. We commend SHED for taking immediate action; that action, along 

with corrective action taken in response to our recommendations, should continue to 

improve the safety posture within the Glenn laboratories. 

Recommendations, Management’s Response, and Evaluation of 

Management’s Response 

Recommendation 1. The Director, Safety and Mission Assurance, Glenn Research Center, 

should ensure that the Safety, Health, and Environmental Division develops a process that 

will comprehensively define the laboratory universe for facility safety and health inspections 

that includes, at a minimum, a periodic reconciliation between the Safety, Health, and 

Environmental Division’s list of laboratories with active safety permits against the Facility 

Division’s list of total Glenn laboratories. 

Recommendation 2. The Director, Safety and Mission Assurance, Glenn Research Center, 

should ensure that the Safety, Health, and Environmental Division 

a. revise the Glenn Safety Manual, Chapter 24, to require inspectors to annotate the 

building number and the specific laboratories that were inspected during all basic and 

detailed inspections; and 

b. require the safety and health violation database be monitored, by severity code, to 

identify and notify management of all violations that are past due and require a 

corrective action plan. 

Recommendation 3. The Director, Safety and Mission Assurance, Glenn Research Center, 

should ensure that the Safety, Health, and Environmental Division coordinate a laboratory 

safety stand-down day, that, at a minimum, requires that the Principal Investigators and their 
RESULTS

14 REPORT NO. IG-07-032 

staff conduct a self-assessment based on the Safety, Health, and Environmental Division’s 

checklists. 

Recommendation 4. The Director, Safety and Mission Assurance, Glenn Research Center, 

should ensure that the Safety, Health, and Environmental Division 

a. record and analyze the results of the laboratory self-assessments and issue 

violation notices in accordance with the Glenn Safety Manual; 

b. identify and address, on a Center-wide basis, any systemic laboratory safety issues 

noted during the analysis; and 

c. based on the number of violations, conduct random or total follow up inspections 

to ensure that appropriate corrective action was taken. 

Management’s Response. The Director, Glenn Research Center, concurred, and 

provided a corrective action plan that addresses each of the recommendations. He stated 

that the Safety Branch would conduct an immediate reconciliation of the Safety, Health, 

and Environmental Division’s safety permit list with the list of laboratories maintained 

by the Facility Division. Once the reconciliation is complete, Safety Branch personnel 

will physically review the laboratories identified as not having active safety permits and, 

if necessary, issue violation notices in accordance with the Glenn Safety Manual. The 

Safety Branch will also establish a process to ensure that the safety permit tracking 

system is updated when laboratories are established or terminated or if the hazards 

associated with a specific laboratory change. 

Regarding the laboratory safety inspections, the Center Director stated that the Glenn 

Safety Manual will be revised to require inspectors to annotate the building number and 

specific laboratory inspected during all basic and detailed inspections. In addition, the 

safety and health violation database will be monitored for past-due violations, and when 

identified, the cognizant managers will be required to present a closure plan to the Center 

Operations Management Council. 

The Center Director also agreed to hold a Center-wide safety stand-down day in 

conjunction with Center-wide safety day events. During the stand-down day, the 

laboratory principal investigators, supervisors, and employees will be required to conduct 

and document self-assessments based on the existing laboratory safety checklists. Any 

safety violations identified will be immediately corrected or documented in the safety and 

health violation database. The violations will be trended to identify any systemic 

laboratory safety concerns. 

Evaluation of Management’s Response. Management’s comments are responsive. The 

recommendations are resolved and will be closed upon completion and verification of 

management’s corrective action 
APPENDIX A 

REPORT NO. IG-07-032 15 

APPENDIX A 

Scope and Methodology 

We collected, reviewed, and analyzed guidance and documents relating to laboratory 

safety and the Glenn safety permit system. Specifically, we evaluated OSHA 

requirements, Executive Orders, and applicable NASA and Glenn safety guidance. We 

also reviewed selected laboratory safety permits, SOPs, laboratory inspection results, 

corrective action plans, and facility database information. We interviewed Glenn 

officials including, the SHED Division and branch chiefs, Area Safety Committee 

chairpersons, and Glenn senior management to obtain an overview of the Glenn safety 

program and to gain an in-depth understanding of the safety permit process and 

laboratory inspection program. 

We reviewed laboratory operations in 22 Glenn laboratories, the laboratories were 

selected for review by the Office of Inspector General (OIG) Safety Manager on the basis 

of severity of operational hazards identified in laboratory safety permits. During the 

reviews, we observed laboratory operations and interviewed laboratory management and 

staff to determine if each laboratory operated with the appropriate permits, maintained 

standard operating procedures, properly managed hazardous chemicals, had appropriate 

engineering controls and safeguards, maintained cleanliness, and met fire standards. 

We compared the results of our inspections to the results of Glenn safety, occupational 

health, health physics, and chemical management inspections performed in calendar year 

2006 and the first quarter of calendar year 2007. We obtained the results of those safety 

inspections by querying the Glenn facility inspection database and reviewing associated 

inspection checklists. We also queried NASA’s Incident Reporting Information System 

for the 17-month period from January 2006 through May 2007, to identify mishaps and 

close calls that were reported at Glenn and determine if any of those mishaps and close 

calls were indirectly related to laboratory operations and the types of noncompliance 

issues that we identified. 

We performed this review at the Glenn Research Center from May 2006 through 

June 2007. 

Use of Computer-Processed Data. We did not perform a detailed assessment of the 

reliability of the data reported in the Glenn facility inspection database or the Incident 

Reporting Information System. We reviewed the checklists that supported the facility 

inspection database but could not validate the results as the checklists represented 

laboratory conditions at a certain point in time. We did not review supporting 

documentation for the Incident Reporting Information System. However, changes in the 
APPENDIX A 

16 REPORT NO. IG-07-032 

inspection results and the incidents reported would not change our conclusions or 

recommendations. 

Review of Internal Controls 

We reviewed internal controls for Glenn laboratory safety to include applicable policies 

and procedures and the oversight activities of the SHED and the Area Safety 

Committees. We identified weaknesses in the SHED oversight activities, specifically 

concerning the facility health and safety inspection program. Implementing the 

recommendations in this report to comprehensively address the inspection program 

should improve the internal controls over laboratory safety. 

Prior Coverage 

During the last 5 years, the Government Accountability Office and the NASA Office of 

Inspector General have not issued any reports of particular relevance to the subject of this 

report. 
APPENDIX B 

REPORT NO. IG-07-032 17 

OIG REVIEW RESULTS
APPENDIX B 

18 REPORT NO. IG-07-032 
APPENDIX B 

REPORT NO. IG-07-032 19 
APPENDIX B 

20 REPORT NO. IG-07-032 
APPENDIX B 

REPORT NO. IG-07-032 21 
APPENDIX B 

22 REPORT NO. IG-07-032 
APPENDIX B 

REPORT NO. IG-07-032 23 
APPENDIX B 

24 REPORT NO. IG-07-032 
APPENDIX B 

REPORT NO. IG-07-032 25 
APPENDIX B 

26 REPORT NO. IG-07-032 
APPENDIX B 

REPORT NO. IG-07-032 27 
APPENDIX B 

28 REPORT NO. IG-07-032 
APPENDIX C 

REPORT NO. IG-07-032 29 

BASIC INSPECTION CHECKLIST
APPENDIX C 

30 REPORT NO. IG-07-032 
APPENDIX C 

REPORT NO. IG-07-032 31 
APPENDIX D 

32 REPORT NO. IG-07-032 

DETAILED INSPECTION CHECKLIST
APPENDIX D 

REPORT NO. IG-07-032 33 
APPENDIX D 

34 REPORT NO. IG-07-032 
APPENDIX D 

REPORT NO. IG-07-032 35 
APPENDIX D 

36 REPORT NO. IG-07-032 
APPENDIX D 

REPORT NO. IG-07-032 37 
APPENDIX D 

38 REPORT NO. IG-07-032 
APPENDIX D 

REPORT NO. IG-07-032 39 
APPENDIX D 

40 REPORT NO. IG-07-032 
APPENDIX E 

REPORT NO. IG-07-032 41 

MANAGEMENT COMMENTS
APPENDIX E 

42 REPORT NO. IG-07-032 
APPENDIX E 

REPORT NO. IG-07-032 43 
APPENDIX E 

44 REPORT NO. IG-07-032 
APPENDIX E 

REPORT NO. IG-07-032 45 
APPENDIX E 

46 REPORT NO. IG-07-032 
APPENDIX E 

REPORT NO. IG-07-032 47 
APPENDIX E 

48 REPORT NO. IG-07-032 
APPENDIX F 

REPORT

REPORT NO. IG-07-032 49 

REPORT DISTRIBUTION

National Aeronautics and Space Administration 

Administrator 

Deputy Administrator 

Chief of Staff 

Chief Safety and Mission Assurance 

Assistant Administrator for Internal Controls and Management Systems 

Center Director, Glenn Research Center 

Director for Safety and Mission Assurance Directorate, Glenn Research Center 

Chief for Safety, Health, and Environmental Division, Glenn Research Center 

Non-NASA Organizations and Individuals 

Office of Management and Budget 

Deputy Associate Director, Energy and Science Division 

Branch Chief, Science and Space Programs Branch 

Government Accountability Office 

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

Management and Assurance 

Director, NASA Issues, Office of Acquisition and Sourcing Management 

Congressional Committees and Subcommittees, Chairman and 

Ranking Member 

Senate Committee on Appropriations 

Senate Subcommittee on Commerce, Justice, Science, and Related Agencies 

Senate Committee on Commerce, Science, and Transportation 

Senate Subcommittee on Space, Aeronautics, and Related Sciences 

Senate Committee on Homeland Security and Governmental Affairs 

House Committee on Appropriations 

House Subcommittee on Commerce, Justice, Science, and Related Agencies 

House Committee on Oversight and Government Reform 

House Subcommittee on Government Management, Organization, and Procurement 

House Committee on Science and Technology 

House Subcommittee on Investigations and Oversight 

House Subcommittee on Space and Aeronautics 

REPORT NO. IG-07-032 51 

Major Contributors to the Report: 

Carol Gorman, Director, Space Operations and Exploration Directorate 

Ronald Yarbrough, Project Leader 

Michael Bruns, Lead Auditor 

Michael Brant, Auditor 

Eugene Bauer, Auditor 

Janet Overton, Report Process Manager 
SEPTEMBER 24, 2007 

REPORT No. IG-07-032 

OFFICE OF AUDITS

OFFICE OF INSPECTOR GENERAL

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