DECEMBER 13, 2010

AUDIT REPORT

REPORT NO. IG-11-004 (ASSIGNMENT NO. A-09-010-00)

OFFICE OF AUDITS

REVIEW OF THE JET PROPULSION LABORATORY’S 

OCCUPATIONAL SAFETY PROGRAM 

OFFICE OF INSPECTOR GENERAL

National Aeronautics and 

Space Administration

 
REPORT NO. IG-11-004 

Final report released by:

Paul K. Martin

Inspector General

Acronyms 

AOA Annual Operating Agreement 

C.F.R. Code of Federal Regulations

FY Fiscal Year

IFO Institutional/Facilities/Operational

IRIS Incident Reporting Information System

JPL Jet Propulsion Laboratory 

NASA National Aeronautics and Space Administration

NPD NASA Policy Directive 

NPR NASA Procedural Requirements

OIG Office of Inspector General

OSHA Occupational Safety and Health Administration

OSMA Office of Safety and Mission Assurance 
DECEMBER 13, 2010

REPORT NO. IG-11-004 

OVERVIEW

REVIEW OF THE JET PROPULSION LABORATORY’S 

OCCUPATIONAL SAFETY PROGRAM

The Issue

Working in the construction industry is one of the most dangerous occupations in the 

United States. According to the Bureau of Labor Statistics, 969 construction workers 

died from work-related injuries in 2008, and these deaths accounted for 19 percent of all 

work-related fatalities.

1

 During that same year, 322,700 non-fatal construction injuries 

occurred, which account for 7 percent of all work-related injuries. The most common 

construction hazards are falls, both in place and from height; electrocution; 

malfunctioning equipment (e.g., cranes, forklifts, and other machinery); and trench 

cave-ins.2

We initiated this audit in response to a 

series of mishaps and employee allegations of unsafe and unhealthful working 

conditions during construction operations 

at the Jet Propulsion Laboratory (JPL), a 

federally funded research and development 

center owned by NASA and operated 

pursuant to contract by the California 

Institute of Technology (Caltech).3 In one 

instance brought to our attention, eight 

subcontractor employees entered a 

collapsed and unprotected trench to repair 

a damaged communications conduit (see 

Figure 1). This unsafe act placed the 

workers at risk of serious injury or loss of 

life due to the potential for additional collapse of the trench and raised serious questions 

about the oversight and supervision of construction safety at JPL.

The overall objective of this audit was to determine whether JPL had implemented 

appropriate internal controls related to oversight of contractors and subcontractors who 

 

1 U.S. Department of Labor, Bureau of Labor Statistics, USDL 09-0979, August 20, 2009. News Release, 

“National Census of Fatal Occupational Injuries in 2008.” 

2 Occupational Safety and Health Administration (OSHA), OSHA Compliance Assistance Quick Start for 

the Construction Industry, OSHA Publications 3146, 3252, 3075, 3215, and 2226.

3 Prime contract NAS7-03001, effective October 1, 2003.

Figure 1. Workers in Collapsed, Unprotected Trench

 at JPL

Source: Vanir Construction Management, Inc. (July 18,

2008)
OVERVIEW

ii REPORT NO. IG-11-004 

perform on-site construction projects. Specifically, we examined whether the JPL 

Occupational Safety Program Office (JPL Occupational Safety Office) had implemented 

an effective process to report, investigate, and document mishaps, close calls, and lessons 

learned.4 We also evaluated whether JPL and its subcontractors were compliant with 

Federal, state, and local laws and regulations, as well as contractually mandated safety 

requirements. During the course of the audit, we expanded our audit objectives to 

determine whether the two NASA offices with oversight responsibility for worker 

safety – the NASA Management Office and the Office of Safety and Mission Assurance 

(OSMA) – had conducted sufficient oversight of the JPL Occupational Safety Office to 

ensure that contractually mandated occupational safety and health requirements were 

effectively implemented at JPL. Additional details of the audit’s scope and methodology 

are in Appendix A. 

Results

We found that the JPL Occupational Safety Office had ineffective management systems 

and controls for construction safety. We also found that although OSMA had procedures 

in place intended to ensure that JPL had implemented contractually mandated safety 

requirements, it failed to follow those procedures. In addition, the NASA Management 

Office did not have policies or procedures to ensure that JPL had fully implemented 

contractually mandated safety requirements. As a result, OSMA and NASA 

Management Office personnel did not identify the JPL Occupational Safety Office’s

internal control deficiencies and NASA management did not have the information 

required to make knowledgeable risk acceptance and mitigation decisions, which in turn 

placed JPL personnel and facilities at increased risk. 

The JPL Occupational Safety Office Did Not Effectively Identify Occupational 

Safety Program Budget Requirements. The JPL Occupational Safety Office develops 

requirements and provides budget and resource estimates to the JPL Office of Safety and 

Mission Success. However, the JPL Occupational Safety Office’s budget management 

process lacked the detail necessary to identify, prioritize, track, monitor, or assess 

progress for functions related to construction safety. Moreover, the JPL Occupational 

Safety Office’s annual operating budget was inconsistent with the provisions defined in 

JPL’s Annual Operating Agreement (AOA).

5

 As a result, the JPL Occupational Safety 

Office’s budget management process was ineffective in measuring performance for 

construction safety-related functions such as confined space entry, asbestos and lead 

abatement, fall protection, and construction drawing reviews. In addition, there was no 

 

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

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

property. Mishap classifications range from a Type A Mishap, the most severe, to a close call, the least 

severe.

5 An AOA is a management plan that defines Center safety and health requirements and the resources 

required to meet those requirements. In addition, the AOA defines the metrics used to measure the 

effectiveness of safety and mission assurance processes.
OVERVIEW

REPORT NO. IG-11-004 iii

assurance that the resources allocated to the JPL Occupational Safety Office were

sufficient to perform construction safety inspections and other programmatic oversight. 

The JPL Occupational Safety Office’s Construction Safety Oversight Was 

Ineffective. We found that the JPL Occupational Safety Office’s oversight process for 

construction safety was ineffective in identifying unsafe acts or unhealthful conditions. 

The oversight process was hampered by the Occupational Safety Office’s practice of 

assigning construction supervisors and safety personnel to its Construction Safety Group

on a rotational basis, which resulted in high personnel turnover and a loss of project 

knowledge. In addition, as safety personnel rotated into and out of the Construction 

Safety Group, they did not receive sufficient training to educate them in identifying and 

abating hazards typically found during construction projects. As a result, safety hazards 

were not recognized during the construction design review process, the building and 

structural inspection process, or the hazard abatement process. For example, in 2009 the 

JPL Occupational Safety Office reviewed and approved design drawings and accepted a 

building that was constructed with a rooftop parapet that was not in compliance with 

California Occupational Safety and Health Administration (OSHA) standards. As a 

result, NASA spent an additional $11,836 to build guardrails to abate fall hazards. 

Additionally, the oversight process did not comply with JPL internal standard operating 

procedures that require the use of a standardized checklist during inspections and did not 

comply with the inspection requirements in NASA Procedural Requirements (NPR) 

8715.1, Chapter 4, “Inspection and Abatement.”6

 The NPR requires that all inspections 

be documented and an abatement plan developed for conditions that take more than 

30 calendar days to correct, that a summary of all open abatement plans be submitted as 

part of JPL’s input to NASA’s annual reporting requirements, and that a risk assessment 

process be used to analyze and evaluate overall risk potential.7

 

In addition, the JPL Occupational Safety Office did not document risk assessments or the 

prioritization of reported hazards stemming from employee complaints. We reviewed the 

95 unsafe or unhealthful incidents reported to that office by JPL employees from October 

2007 through early July 2009 and found that in only 2 instances was there any evidence 

that the JPL Occupational Safety Office had conducted any kind of risk assessment or 

hazard prioritization. Further, of those 95 reported incidents, only 7 showed that the 

Office had conducted additional inspections to ensure that the hazard was abated and 

only 8 showed that the office had provided follow-up information to the reporting 

employees affected by the reported hazard.

 

6 On March 30, 2004, NASA renamed NASA Procedures and Guidelines 8715.1 as NPR 8715.1, “NASA 

Occupational Health and Safety Programs,” without substantially changing its substance. Hereafter, we 

refer to the NASA Procedures and Guidelines as the NPR.

7 NPR 8715.3C, “NASA General Safety Program Requirements (w/Change 4 dated 7/20/09),” defines risk 

management as an organized, systematic decision-making process that efficiently identifies, analyzes, 

plans, tracks, controls, communicates, and documents risk to increase the likelihood of achieving project 

goals. The NPR defines risk assessment as a process of qualitative risk categorization or quantitative risk 

(safety) estimation, followed by the evaluation of risk significance.
OVERVIEW

iv REPORT NO. IG-11-004 

The JPL Occupational Safety Office’s Mishap, Close Call, and Hazard Reporting

Processes Are Inefficient, Incomplete, and Untimely. We found that the JPL 

Occupational Safety Office did not implement an efficient and effective mishap, close 

call, and hazard reporting system as required by the prime contract. The reporting system 

involved multiple reporting processes that were inefficient in consolidating incident data 

to perform trending and root cause analysis for recurring problems and subsequently 

communicating lessons learned.8 In addition, the reporting process did not ensure that

mishaps and close calls were documented and all incident data were recorded in a timely 

manner into the NASA Incident Reporting Information System (IRIS). For example, the 

collapse of a construction trench described previously, which caused approximately 

$329,000 of damage to JPL communication lines, was not reported to the JPL 

Occupational Safety Office within 24 hours as required by the prime contract. In fact, 

this serious incident was not reported to the JPL Occupational Safety Office until 3 days 

after it occurred, causing subcontractor employees to continue to be exposed to hazardous 

conditions when they entered the unshored trench. Had the JPL Occupational Safety 

Office been notified in a timely manner as required, JPL Occupational Safety Office 

personnel would have been able to respond to the scene and make recommendations for 

safe entry into the collapsed trench. 

The NASA Management Office and OSMA Did Not Effectively Oversee the JPL 

Occupational Safety Office. We found that the NASA Management Office and OSMA

did not provide sufficient oversight to ensure programmatic compliance by the JPL 

Occupational Safety Office. First, the NASA Management Office did not develop plans 

or resource requirements to oversee JPL’s short-term and long-term operations or 

coordinate oversight activities with OSMA strategic audit plans for JPL. Specifically, the 

NASA Management Office and OSMA did not coordinate their review of the JPL 

Occupational Safety Office’s corrective action plan in response to audit findings or their 

activities to verify that the JPL Occupational Safety Office had taken the specified

corrective actions. Second, periodic oversight audits by OSMA did not identify instances 

in which the JPL Occupational Safety Office was not in compliance with NPR 8715.1. 

This inadequate oversight was caused, at least in part, by the absence of clearly defined 

oversight roles and responsibilities between the NASA Management Office and OSMA. 

Although the NASA Management Office safety official had developed a list of 166 

duties, we found that the NASA Management Office did not have a documented policy 

for safety oversight procedures that defined the NASA Management Office’s oversight 

roles and responsibilities. The Management Office had not assessed resource 

requirements to fulfill its oversight responsibilities at JPL and had no strategic plan to 

oversee JPL safety activities. Moreover, the NASA Management Office had only one 

civil service employee to perform all activities related to overseeing the safety of 

approximately 5,000 NASA employees and contractors on the 155-acre JPL campus, 

 

8 Root cause analysis is a structured evaluation method that identifies the root causes of an undesired 

outcome and the actions required to prevent recurrence. Root cause analysis helps determine what 

happened, how it happened, and why it happened and the identification of appropriate corrective actions 

to prevent recurrence.
OVERVIEW

REPORT NO. IG-11-004 v 

which contains 136 buildings and 61 structures. In our judgment, one person cannot 

effectively provide reasonable assurance that the requirements of NPR 8715.1 are being 

met at a facility as large as JPL.

In addition, although OSMA conducted periodic Institutional/Facilities/Operational (IFO)

audits intended to provide independent verification that JPL’s facilities and operations 

were in compliance with applicable NASA safety requirements, these audits did not 

identify instances of program noncompliance. Specifically, we found that the most recent 

IFO audit addressed only 9 of the 142 requirements (less than 7 percent) contained in

NPR 8715.1 and excluded such key topics as financial management, inspection and 

abatement, safety and health training, recordkeeping, reporting requirements, and Center 

self-evaluation of occupational safety and health programs. In our judgment, it is 

essential to address these topics in order to independently verify that JPL is compliant 

with NASA safety requirements. 

Furthermore, OSMA did not use JPL’s AOA as a means to validate program resources. 

An AOA identifies a Center’s safety and health requirements and the resources required 

to meet these requirements. Although there was no contractual requirement for JPL to 

submit an AOA, JPL has submitted an AOA to OSMA since 2006. However, JPL 

management did not include in these AOAs all of the elements requested of Centers by 

OSMA. In addition, OSMA did not request any supporting documentation of JPL’s 

annual cost estimate and self-evaluation and did not follow the Headquarters Office Work 

Instruction 8700-GB05, Rev. E, “Development and Utilization of Annual Operating 

Agreements,” January 26, 2009, to evaluate whether the AOA included all of NASA’s 

safety and budgetary requirements. Had OSMA performed its evaluation of the JPL 

AOA in accordance with the Work Instruction, it would likely have identified the 

deficiencies in the JPL Occupational Safety Office’s budget management process 

previously discussed. 

Management Action

During the course of our audit, the JPL Occupational Safety Office took steps to improve 

its hazard reporting processes, including incorporating a risk assessment process when 

responding to employee reports of unsafe or unhealthful conditions and creating 24-hour 

telephone and Web access for JPL personnel to report mishaps, close calls, and 

unhealthful or unsafe conditions. In addition to the actions management has already 

taken, OSMA, the NASA Management Office, and the JPL Occupational Safety Office

should take the following steps, which we believe will help ensure compliance with 

contractual safety requirements and reduce risk to personnel and facilities. 

Specifically, we recommended that the JPL Office of Safety and Mission Success 

reassess the JPL Occupational Safety Office resource planning process to maintain 

consistency with NPR 8715.1, to include implementing a budgetary process that 

prioritizes and establishes measurable and attainable program goals using a risk 

assessment process. In addition, the JPL Office of Safety and Mission Success should 
OVERVIEW

vi REPORT NO. IG-11-004 

reassess labor resource and training requirements to ensure compliance with the prime 

contract and maintain staff competency. 

To improve management of the construction safety program and hazard reporting 

processes, the JPL Occupational Safety Office should implement a standardized 

construction safety inspection process that complies with JPL’s own internal operating 

procedures and NASA Procedural Requirements. The JPL Occupational Safety Office 

should also establish procedures that will improve its internal oversight of subcontractor 

safety plans and engineering design drawings and review employee competencies and 

develop training requirements that ensure that Construction Safety Group members 

obtain the training necessary. 

To improve the JPL mishap, close call, and employee hazard reporting system, the JPL 

Occupational Safety Office should reassess its reporting system to improve timeliness 

and completeness and ensure compliance with NPR 8715.1, establish procedures for 

documenting and disseminating lessons learned, conduct employee training to provide 

guidance on proper identification of root causes, and reinforce the concept of sharing 

lessons learned. 

To ensure compliance with contractual safety requirements and reduce risk to personnel 

and facilities, NASA should clearly define the roles and responsibilities of the NASA 

Management Office and OSMA in providing oversight of the JPL occupational safety 

program. In addition, the NASA Management Office should establish a written safety 

oversight policy and assess resource requirements to ensure that it has adequate resources 

to meet its responsibilities.

Finally, OSMA should revise its audit processes to include steps that will ensure JPL’s 

compliance with NPR 8715.1 requirements and coordinate with the NASA Management 

Office to establish a contractual requirement for JPL to execute an effective AOA that 

complies with NASA procedures. 

We submitted a draft of this report to NASA and JPL management on September 24, 

2010, and requested a single, coordinated response to our recommendations. However, 

we received separate comments from NASA and JPL. Moreover, NASA’s comments 

were further divided into separate responses from the NASA Management Office and 

OSMA (see Appendix B). 

JPL and the NASA Management Office concurred with the majority of our 

recommendations and stated they would take steps to: 

• reassess labor resource and training requirements to ensure compliance with the 

prime contract and maintain staff competency;

• implement a standardized construction safety inspection process that complies 

with internal operating procedures and NASA Procedural Requirements; 
OVERVIEW

REPORT NO. IG-11-004 vii

• establish procedures that will improve internal oversight of subcontractor safety 

plans and engineering design drawings; 

• review employee competencies and develop training requirements that ensure that 

Construction Safety Group members obtain necessary training; 

• reassess the JPL Occupational Safety Office’s reporting system to improve 

timeliness and completeness and reinforce the concept of sharing lessons learned; 

• clearly define the roles and responsibilities of the NASA Management Office and 

OSMA in providing oversight of the JPL occupational safety program; and 

• establish a written safety oversight policy and assess resource requirements to 

ensure that the NASA Management Office has adequate resources to meet its 

responsibilities.

These planned actions are responsive to our corresponding recommendations, and 

accordingly we consider these recommendations to be resolved. We will close these

recommendations upon completion and verification of the proposed corrective actions. 

However, the comments provided by JPL to one recommendation and the comments 

provided by OSMA were unresponsive to our recommendations to: 

• implement a budgetary process that prioritizes and establishes measurable and 

attainable program goals using a risk assessment process; 

• assess internal audit processes and include steps to ensure JPL’s compliance with 

safety requirements; 

• review JPL’s compliance with safety program requirements; and 

• coordinate with the NASA Management Office to establish a contractual 

requirement for JPL to annually submit an AOA and ensure that future 

Agreements are reviewed in accordance with the applicable work instruction.

Accordingly, we consider these recommendations to be unresolved. 

With respect to our recommendation regarding the budgetary process, JPL stated that the 

occupational safety budget process already uses risk assessments and has established 

measurable and attainable program goals that comply with safety program requirements. 

However, during our review we found no evidence of risk assessments being used to 

support budgetary decisions. Rather, we found that the JPL Occupational Safety Office 

budget was negotiated informally during “round table discussions.” In our judgment, JPL 

needs a formal, documented risk assessment process to effectively allocate funding to 

program elements based on prioritized risks. 
OVERVIEW

viii REPORT NO. IG-11-004 

JPL also stated that construction safety elements were assigned a unique project/task 

number in order to capture all related cost activities and the safety budget was distributed 

by expenditure type, such as labor and purchase order. In our judgment, this budgeting 

methodology does not lend itself to effective evaluation of whether functional areas like 

construction oversight, construction job walks, construction drawing review, fall 

protection, and safety and health training were adequately staffed and supported or 

whether sufficient funds were allocated to accomplish individual tasks. 

In response to our recommendations that the Chief of Safety and Mission Assurance 

assess the IFO audit processes and include steps to ensure JPL’s compliance with 

NPR 8715.1 and to review JPL’s compliance with NPR 8715.1, OSMA stated that the 

NPR is not applicable to contractor employees, including employees of JPL/Caltech, and 

therefore the criteria we cite for conducting the audit is not applicable. OSMA also stated 

that its requirements for the performance of IFO audits at JPL are contained within 

NPR 8705.6A, “Safety and Mission Assurance Audits, Reviews, and Assessments,” 

April 9, 2009, and only applicable specifically to the NASA Management Office. 

Further, OSMA stated that it was unfortunate that the predecessor to NPR 8715.1 was 

applied to the JPL contract because it has created confusion. OSMA concluded that, in 

order to avoid future misinterpretations regarding these requirements, it will review the 

applicable NPRs and the JPL prime contract to determine whether additional clarifying 

modifications are appropriate.

In our judgment, NPR 8715.1 does apply to JPL because it is a federally funded research 

and development center wholly owned by the Federal Government. NPR 8715.1 states 

that the NPR is applicable to all NASA Centers and Component Facilities and to all 

NASA organizations, equipment, property, and facilities. OSMA’s implication that the 

most comprehensive NPR on safety requirements was included in the JPL contract by 

mistake and that the IFO audit process should only apply to the NASA Management 

Office at JPL does little to bolster our confidence in NASA’s oversight of the JPL safety 

program. 

In response to our recommendation that the Chief of Safety and Mission Assurance 

coordinate with the NASA Management Office to establish a contractual requirement for 

JPL to submit an AOA and ensure that future Agreements are reviewed in accordance 

with the applicable work instruction, OSMA stated that there are no established 

requirements for AOAs and that the call letter requesting Centers to submit the AOA 

provides guidance rather than a requirement. OSMA also stated that because the AOA is 

used to provide insight into the process and not as an oversight mechanism, making it a 

contractual requirement may be detrimental to open communication between JPL and 

NASA. These comments do not address our conclusion that had the AOA been reviewed 

using OSMA’s internal work instruction, the deficiencies in the budget management 

process we noted would likely have been discovered. 

Moreover, we disagree with OSMA’s assertion that the AOA is not intended as an

oversight mechanism. The guidance provided in the July 2009 call letter states that “the 

completed AOA provides the Chief, SMA [Safety and Mission Assurance], with an 
OVERVIEW

REPORT NO. IG-11-004 ix

oversight tool to understand customer requirements at individual Centers and to establish 

a baseline to assess the effectiveness of the Center’s functional SMA [safety and mission 

assurance] processes.” In addition, the AOA JPL submitted provides that it establishes 

an agreement between the Director of JPL, the Director for the JPL Office of Safety and 

Mission Success, the NASA Chief of Safety and Mission Assurance, and the NASA 

Associate Administrator regarding Office of Safety and Mission Success services to be 

provided to JPL programs/projects, including goals and metrics, and the Office of Safety 

and Mission Assurance-funded tasks. The Chief of Safety and Mission Assurance’s 

signature on the AOA attesting to concurrence and the Associate Administrator’s 

signature attesting to approval implies that the document was reviewed and used as an 

oversight tool by OSMA. 

 

DECEMBER 13, 2010

REPORT NO. IG-11-004 

CONTENTS

INTRODUCTION

Background __________________________________________ 1 

Objectives ___________________________________________ 2 

RESULTS

The JPL Occupational Safety Office Did Not Effectively Identify 

Occupational Safety Program Budget Requirements_________ 4 

The JPL Occupational Safety Office’s Construction Safety 

Oversight Was Ineffective in Identifying Unsafe Acts and

Unhealthful Conditions _______________________________ 8 

The JPL Occupational Safety Office’s Mishap, Close Call, and 

Hazard Reporting Processes Are Inefficient, Incomplete, 

and Untimely______________________________________ 17

The NASA Management Office and OSMA Did Not Ensure that 

Occupational Safety and Health Program Requirements 

Were Effectively Implemented at JPL ___________________ 24

APPENDIX A 

Scope and Methodology________________________________ 33

Review of Internal Controls _____________________________ 34

Prior Coverage _______________________________________ 34

APPENDIX B 

Management Comments _______________________________ 35

APPENDIX C 

Report Distribution ___________________________________ 44

DECEMBER 13, 2010

REPORT NO. IG-11-004 1

INTRODUCTION

Background

The Jet Propulsion Laboratory (JPL) is a 

federally funded research and development 

center owned by NASA and operated 

pursuant to contract by the California 

Institute of Technology (Caltech), a private 

nonprofit research university located in 

Pasadena, California. The primary mission 

of JPL is to conduct Earth science and deep 

space and interplanetary exploration.

The prime contract between NASA and 

Caltech was awarded in November 2002 

and was initially valued at approximately 

$7.5 billion.

9 The contract covers all JPL 

research and development activities as well 

as the management and institutional operation of JPL. The JPL Director is a Caltech 

employee, appointed by the Caltech president with concurrence from the NASA 

Administrator. JPL has an annual budget of approximately $1.6 billion and a workforce 

of approximately 5,000 employees, of which about 50 are full-time civil service 

employees. The JPL Director oversees land, buildings, and structures (see Figure 2) with 

a value exceeding $1.7 billion.

10

NASA’s Office of Safety and Mission Assurance (OSMA) is the NASA Headquarters 

office responsible for policy direction, functional oversight, and assessment of safety 

activities at NASA Centers and facilities. The organizations responsible for safety and 

health at JPL include the NASA Management Office and the JPL Office of Safety and 

Mission Success. The NASA Management Office reports to NASA’s Agency Operations

and is staffed by civil service personnel who oversee the prime contract for NASA. The 

JPL Office of Safety and Mission Success is staffed by Caltech employees and is 

responsible for assessing and reducing mission risk and ensuring JPL compliance with 

Federal, state, and local laws and regulations, as well as contractually mandated safety 

requirements.

9 Through award fees and term extensions, the total contract value is potentially $15 billion, as described in 

the OIG audit report “NASA Should Reconsider the Award Evaluation Process and Contract Type for the 

Operation of the Jet Propulsion Laboratory (Redacted)” (IG-09-022-R, September 25, 2009).

10 Property replacement value as of October 26, 2009, for properties located in the United States. On-site 

property includes 197 buildings and structures throughout 212 acres.

Figure 2. NASA’s Jet Propulsion Laboratory
INTRODUCTION

2 REPORT NO. IG-11-004 

The JPL Office of Safety and Mission Success manages JPL’s Occupational Safety 

Program Office (JPL Occupational Safety Office). Within the JPL Occupational Safety 

Office is a Construction Safety Program 

Group (Construction Safety Group), 

which oversees construction project 

safety at JPL. JPL Occupational Safety 

Office personnel work with designers, 

facilities construction managers, 

coordinators, subcontractors, and 

contract personnel to assist them in 

complying with safety requirements 

from project preparation to project 

completion. The Construction Safety 

Group provides safety oversight during 

all phases of construction by identifying 

and correcting potential safety and 

health-related problems. 

From October 2006 through March 2009, JPL initiated 773 construction projects with a 

total cost of approximately $130 million. The most significant project was the 

construction of the Flight Projects Center, with an estimated cost of $66 million over a 

2-year period. In January 2009, the NASA Office of Inspector General (OIG) received 

information regarding two mishaps that occurred during construction of the Flight 

Projects Center. The first incident was a trench collapse during excavation that damaged 

critical fiber-optic telecommunication 

cables and exposed workers to a 

potential engulfment hazard during 

repair work (see Figure 3). The second 

incident occurred during the removal of 

concrete forms (see Figure 4), when a 

worker’s finger was crushed between a 

concrete form and wall resulting in the 

partial amputation of the finger.

Objectives

The audit’s overall objective was to 

determine whether JPL implemented 

appropriate internal controls to provide 

effective oversight of contractors and subcontractors performing on-site construction 

projects. Specifically, we examined whether the JPL Occupational Safety Office had 

• implemented an effective process to report, investigate, and document mishaps 

and close calls and to communicate lessons learned; and

Figure 4. Workers Removing Concrete Forms

Source: Vanir Construction Management, Inc. 

(September 4, 2008) 

Figure 3. Workers in Collapsed, Unshored Trench

 at JPL

Source: Vanir Construction Management, Inc. (July 18,

2008)
INTRODUCTION

REPORT NO. IG-11-004 3 

• established adequate oversight procedures to ensure contractor and subcontractor 

compliance with Federal, state, and NASA safety requirements.

During the course of our fieldwork, we found that OSMA had not closed fiscal year (FY) 

2007 audit findings concerning facility safety, lifting devices such as cranes, and mishap 

reporting, and we noted that similar deficiencies remained. As a result, we expanded our 

audit objectives to determine whether NASA conducted sufficient oversight of the JPL 

Occupational Safety Office to ensure that contractually mandated occupational safety and 

health requirements were effectively implemented at JPL. 
RESULTS

4 REPORT NO. IG-11-004 

THE JPL OCCUPATIONAL SAFETY OFFICE DID NOT 

EFFECTIVELY IDENTIFY OCCUPATIONAL 

SAFETY PROGRAM BUDGET REQUIREMENTS 

We found that the JPL Occupational Safety Office did not effectively identify and 

monitor safety-related budget resource requirements for JPL. NASA Procedural 

Requirements (NPR) 8715.1 requires Centers’ budget submissions to include 

appropriate financial estimates to effectively administer NASA’s Occupational 

Safety and Health Program.11 However, the JPL Occupational Safety Office’s 

budget management process did not prioritize safety-related tasks; did not identify, 

track, monitor, or assess progress on construction safety-related functions; and could 

not be used to determine whether the staff resources dedicated to safety-related 

functions were sufficient. Consequently, JPL officials had no assurance that they 

allocated sufficient resources to perform construction safety inspections and other 

programmatic oversight. 

Contract and Policy Requirements for Allocation of Resources to 

the Occupational Safety Program

The JPL prime contract requires that JPL management ensure that resources are allocated 

effectively to address environmental, safety and health, programmatic, and operational 

considerations.12 The contract also requires JPL management to protect the public and 

employees from injury or illness and facilities and work products from damage, as well 

as ensure that JPL’s environmental, safety, and health system is integrated with business 

processes for work planning, budgeting, authorization, execution, and change control.13 

In addition, the prime contract requires that JPL’s budget submission include appropriate 

resources to effectively implement and administer NASA’s Occupational Safety and 

Health Program, including sufficient personnel, abatement of unsafe or unhealthful 

working conditions, safety and health equipment, contracts to identify or evaluate unsafe 

working conditions, promotional cost, technical information, medical surveillance 

programs, and safety and health training, in addition to inspectors having sufficient 

training and experience in safety and health to recognize and abate safety and health

hazards.14 

 

11 NPR 8715.1, “NASA Occupational Health and Safety Programs w/Change 3 (02/13/06).” 

12 Section H-46, “Integration of Environment, Safety, and Health, into the Contractor’s Management 

System.”

13 Change control is the methodical way of documenting changes in activities, policies, procedures, and 

requirements and of keeping up-to-date records available for all concerned personnel. 

14 NPR 8715.1, Section 2.9, “Financial Management.”
RESULTS

REPORT NO. IG-11-004 5 

Budget Management Process Lacked the Ability to Identify, Track, 

Monitor, and Assess JPL’s Occupational Safety Program 

Our review of the JPL Occupational Safety Office’s FY 2007 through FY 2009 annual 

budget plans found no documentation linking the budget to the Office’s areas of 

responsibility. For example, in FY 2009 the $424,000 the JPL Occupational Safety 

Office budgeted for the Construction Safety Group was distributed by expenditure type – 

such as labor, purchase order, consulting and professional services, training, and travel – 

rather than according to the functions identified in JPL’s FY 2009 Annual Operating 

Agreement (AOA): confined space entry, asbestos and lead oversight, fall protection, 

construction drawing reviews, construction job walks, construction oversight, and safety 

and health training. An AOA defines a Center’s safety and health requirements and the 

resources required to meet those requirements, as well as the metrics used to measure the 

effectiveness and efficacy of safety and mission assurance processes. Because the JPL 

Occupational Safety Office did not align its resources with the functions identified in the 

JPL AOA, it could not effectively evaluate whether these functions were adequately 

staffed and supported or whether sufficient funds had been allocated to accomplish them. 

Moreover, the JPL Occupational Safety Office did not use a risk assessment to determine 

resource requirements or document any budget or personnel resource shortages.15 This 

increased the potential that contractors, subcontractors, and facilities would be placed at 

risk of personal injury or property damage. 

Resources Were Not Effectively Managed to Fulfill Essential Tasks 

The JPL Occupational Safety Office was unable to determine whether allocated funding 

was sufficient to meet the requirements of the prime contract. Specifically, there was no 

assurance that an adequate number of qualified safety professionals were available to 

perform construction safety oversight inspections and other programmatic oversight 

functions such as fall protection, construction drawing review, and construction job 

walks. In addition, we found a lack of planning to ensure that Construction Safety Group 

members received the necessary training to adequately perform their oversight duties 

during construction of the Flight Projects Center. 

Staffing Concerns. In FY 2009, the Occupational Safety Office’s annual budget 

reflected $424,000 for the Construction Safety Group, including labor costs of $365,000 

for three full-time staff members – one supervisor and two construction safety specialists. 

These two specialists were responsible for supporting seven major functions within three

diverse safety programs (confined space entry, asbestos and lead oversight, fall 

protection) and four oversight responsibilities (construction drawing review, 

 

15 NPR 8715.3C states that the primary purpose of risk assessment is to identify and evaluate risks to help

guide decision making and risk management regarding actions to ensure safety and mission success. 

Risk assessment should use the most appropriate methods that adequately characterize the probability,

consequence severities, and uncertainty of undesired events and scenarios.
RESULTS

6 REPORT NO. IG-11-004 

construction job walks, construction safety oversight, and safety and health training), as 

well as responding to calls from employees reporting unsafe and unhealthful conditions. 

In our judgment, two construction safety specialists are not sufficient to cover all required 

safety functions given JPL’s size and the scope of construction projects at the Center.16 

Training Concerns. The lack of planning was also evident in the JPL Occupational 

Safety Office’s budgeting for training. As of July 2009, the JPL Occupational Safety 

Office had budgeted $5,000 but expended $14,000 for the training of 24 staff members. 

This equated to an average of about $200 planned and $583 spent per employee. As 

evidenced by the amount spent as compared to planned, in our judgment, the average 

planned amount was insufficient to train all staff members and to ensure that the 

Construction Safety Group’s specialists received adequate training to maintain the 

competency to fulfill their inspection and oversight responsibilities. For example, the 

tuition for the Occupational Safety and Health Administration (OSHA) Training 

Institute’s Concrete, Forms, and Shoring course is $800 alone, not including travel and 

per diem.17 

Recommendation, Management’s Response, and Evaluation of 

Management’s Response

Recommendation 1. We recommended that the Director of the JPL Office of Safety and 

Mission Success reassess the JPL Occupational Safety Office’s resource planning process to 

maintain consistency with NPR 8715.1 and the AOA functional requirements, to include the 

following actions: 

a. implement a budgetary process that uses risk assessments and establishes 

measurable and attainable program goals based on NPR 8715.1 safety program 

requirements;

b. reassess labor resource requirements to ensure that JPL’s safety program is 

implemented in accordance with the prime contract; and 

c. evaluate funding requirements and allocate sufficient funding to provide training 

to develop and maintain staff competency. 

Management’s Response. JPL management responded with comments provided by the 

Manager of the Finance and Contract Management Division. With regard to 

recommendation 1.a, JPL stated that the occupational safety budget process already uses 

 

16 We note that OSMA’s March 2007 Institutional/Facilities/Operational (IFO) Audit of the Occupational 

Safety Program Office also contains a finding that questions the adequacy of staffing for facilities design 

review for all of the ongoing projects at JPL.

17 This course introduces the student to principles of forms and shoring and the quality of concrete, hot and 

cold weather placing practices, and inspection procedures. Topics include relevant OSHA standards, 

curing of concrete, form removal, and American Society for Testing and Materials (ASTM) standards on 

sampling concrete. 
RESULTS

REPORT NO. IG-11-004 7 

risk assessments and has established measurable and attainable program goals that 

comply with safety program requirements of NASA Procedures and Guidelines 8715.1;18 

that an annual gap analysis is performed relative to the JPL prime contract requirements, 

industry standards, and other regulatory requirements and is used to support budget 

strategy and specific funding needs; and that construction safety elements were assigned 

a unique project/task number in order to capture all related costs, such as personnel 

staffing, training, testing, publication, and document costs. With regard to the other parts 

of our recommendation, JPL stated that it will reassess labor resource requirements 

annually to ensure that the JPL safety program is implemented in accordance with the 

prime contract and that annual funding requirements will be reevaluated and additional 

training provided to develop and maintain staff competency.

Evaluation of Management’s Response. We find JPL’s s comments to 

recommendation 1.a to be nonresponsive and consider the recommendation to be 

unresolved. During our review of the JPL safety budget process we found no evidence of 

risk assessments being used to support budgetary decisions. Rather, we found that the 

JPL Occupational Safety Office budget was developed during informal “round table 

discussions.” In our judgment, JPL needs a formal, documented risk assessment process 

in order to effectively allocate funding to program elements based on prioritized risks. In 

addition, we do not believe that assigning unique project/task numbers and distributing 

the safety budget by expenditure type is sufficient to allow the JPL Occupational Safety 

Office to effectively evaluate whether sufficient funds have been allocated to support 

such functional areas as construction oversight, construction job walks, construction 

drawing review, fall protection, and safety and health training. 

We find management’s planned actions in regard to recommendations 1.b and 1.c to be 

responsive. Accordingly, these recommendations are resolved and will be closed upon 

completion and verification of management’s corrective action. 

 

18 On March 30, 2004, NASA renamed NASA Procedures and Guidelines 8715.1 as NPR 8715.1, “NASA 

Occupational Health and Safety Programs,” without substantially changing its substance. Hereafter, we 

refer to the NASA Procedures and Guidelines as the NPR.
RESULTS

8 REPORT NO. IG-11-004 

THE JPL OCCUPATIONAL SAFETY OFFICE’S 

CONSTRUCTION SAFETY OVERSIGHT WAS 

INEFFECTIVE IN IDENTIFYING UNSAFE ACTS 

AND UNHEALTHFUL CONDITIONS

We found that the JPL Occupational Safety Office’s construction safety oversight 

was ineffective in identifying unsafe acts and unhealthful conditions. The oversight 

processes did not follow NPR 8715.1 requirements to identify, disposition, track, and 

abate safety and health concerns or JPL internal procedures for construction site 

inspections. We attribute this ineffectiveness to high turnover within the 

Construction Safety Group and a lack of sufficient training for Group members. In 

addition, we found that JPL’s reviews of construction documents overlooked unsafe 

designs and accordingly JPL accepted structures that were not built in compliance 

with California OSHA standards. Consequently, NASA incurred additional costs to 

correct these unsafe conditions. 

JPL Standardized Inspection Process 

NPR 8715.1, Chapter 4, “Inspection and Abatement,” includes inspection requirements 

for both construction projects and employee-reported unsafe and unhealthful conditions. 

The NPR requires all inspections to be documented and unsafe or unhealthful conditions 

to be documented on a standardized form, “Notice of Unsafe or Unhealthful Condition” 

(NASA Form 1390), or an equivalent form approved by the Designated Agency Safety 

and Health Official.

19 An abatement plan is required for conditions that take more than 

30 calendar days to correct. A summary of all open abatement plans and a listing of 

those closed during the reporting period are to be provided to the Designated Agency 

Safety and Health Official or designee as part of the Center’s input to the “Annual 

Summary - Occupational Injuries/Illnesses Report” required by NPR 8715.1. The NPR

also requires that a risk assessment process that considers the elements of severity and 

probability of occurrence be used to analyze and evaluate overall risk potential. In

addition, the NPR states that safety and health inspectors are required to have sufficient 

documented training and experience to recognize and evaluate safety and health hazards

in the workplace and suggest corrective actions. 

 

19 NPR 8715.1, paragraph 2.1.2, states that the Designated Agency Safety and Health Official is the Chief 

Health and Medical Officer. The NPR cites OSHA as defining a Designated Agency Safety and Health 

Official as an official designated by the agency head with sufficient authority and responsibility to 

effectively represent the interest of, and support the agency head in the management and administration 

of, the agency’s occupational safety and health program. The Designated Agency Safety and Health 

Official is responsible for ensuring that safety and health officials are appointed at appropriate levels with 

adequate budgets and staffs to implement occupational safety and health programs at all operational 

levels as required by the OSHA provisions set forth in Part 1960 of Title 29 of the Code of Federal 

Regulations (C.F.R.); specifically, Part 1960.6, paragraph (c). 
RESULTS

REPORT NO. IG-11-004 9 

JPL’s internal procedures for the construction oversight process require all inspectors to 

use a standardized checklist and require the Construction Safety Group to: 

• document any deficiencies observed on construction sites using the Construction 

Safety Inspection Report;

• use the data in the inspection database to track trends and leading indicators; 

• communicate trends and leading indicators to the Facilities Construction and 

Engineering Group; and 

• conduct a follow-up inspection to ensure that all noted observations have been 

corrected.20 

JPL Occupational Safety Office Inspections and Document 

Reviews Did Not Detect Workplace Hazards 

The JPL Occupational Safety Office did not apply consistent oversight procedures to 

review subcontractor safety plans and engineering drawings for compliance with safety 

standards. In addition, JPL Occupational Safety Office inspectors did not recognize 

safety hazards during the document review process, the building and structural inspection 

process, and the hazard abatement process.

We reviewed subcontractor safety plans for five construction and facility projects at JPL 

that were active since October 2006 and found that two of these projects were not 

adequately reviewed by the Construction Safety Group. For example, in 2009 JPL 

completed construction of Building 224, a sewage lifting station. The Construction 

Safety Group reviewed and approved the project’s design drawings and accepted the 

facility as built. However, we found that the building was designed and constructed with 

a rooftop parapet less than 36 inches in height, which does not comply with California 

OSHA standards requiring 42-inch guardrails.21 As a result, JPL was required to spend 

an additional $11,836 to build guardrails to abate a potential fall hazard. 

In another case, JPL subcontracted a roof replacement project for 13 buildings. The 

Construction Safety Group reviewed and approved the subcontractor safety plan for 

installing the rooftop fall restraint/arrest systems. However, when we compared the 

installed systems with the manufacturer’s installation guide, we found that they had not 

been installed in accordance with manufacturer recommendations. We contacted the 

manufacturer and confirmed our concerns regarding the hardware used and the 

 

20 JPL Rules DocID 45420, “Safety Inspections,” and Occupational Safety Program Office, “Internal 

Procedures for Inspections of Construction Sites,” July 21, 2006. 

21 California OSHA standards require 42-inch guardrails (or fall restraint/fall arrest systems) at working 

levels more than 30 inches above the floor (California Code of Regulations, Title 8, Chapter 4, 

Subchapter 7, “General Industry Safety Orders,” §3207 and §3210). 
RESULTS

10 REPORT NO. IG-11-004

placement of the anchor points (see Figure 5). The placement allows the cable to rub 

against the sharp, inside edge of the anchor point eyelets, which places additional stress 

on the restraint/arrest cable. Over time, this additional stress could damage the cable and 

lead to the failure of the system.

According to the manufacturer, this faulty installation voided the manufacturer’s 

warranty and placed personnel at increased risk of injury. In addition to the 

manufacturer’s concerns, we also observed that the system was installed in a way that 

required workers to disconnect their safety harness lanyard and then reconnect it at each 

intermediate anchor point. In our judgment, this disconnecting and reconnecting 

increases the potential for a slip and fall. To prevent the likelihood of a slip and fall, a 

double lanyard system needs to be used: workers would attach their first lanyard to the 

restraint/arrest cable; upon arrival at the next intermediate anchor point, workers would 

simply connect their second lanyard ahead of that anchor point before disconnecting their 

first lanyard from the restraint/arrest cable. This process would be repeated as they 

Figure 5. Rooftop of Building 156 

Rooftop Fall Restraint System

Source: Kari Helman of Helman Architects (February 24, 2009)

Workers have to connect/disconnect their safety harness lanyard from the lifeline while traveling 

between the rooftop anchors (illustrated by yellow circles), which were improperly installed.
RESULTS

REPORT NO. IG-11-004 11

traveled along the restraint/arrest cable, thus ensuring continuous protection from a slip 

and fall. 

When we notified the JPL Office of Safety and Mission Success of these issues, it

directed the JPL Occupational Safety Office to correct the problem. However, in our 

judgment, the JPL Occupational Safety Office’s efforts were inadequate because the 

corrective action it implemented still left employees with no fall protection within 6 feet 

of the roof’s edge (see Figure 6). In addition, the JPL Occupational Safety Office did not 

correct the placement of the cable shock absorber, which had been improperly installed 

on the down-slope side of the rooftop and could not absorb the energy generated by a fall.

(a) Inadequate fall restraint system to 

prevent an employee from reaching a fall

point. The most commonly used fall 

protection system is standard guardrails

and ladders with self-closing gates or a 

properly installed personal fall arrest 

system with documented procedures and 

training.

(b) Note distance (red arrow) from ladder and 

edge of roof to the nearest fall arrest system

(in yellow circle at right), which is more than 6

feet from roof edge. Employees accessing this 

area have no fall protection from the ladder 

(yellow circle at left) to the fall arrest system 

noted by the yellow circle at right, which is an 

end point of the cable lifeline, with a shock 

absorber. However, the shock absorber is 

improperly installed on the down-slope end of 

the cable instead of the up-slope end of the 

cable. If an employee was attached to the 

cable and fell off the roof edge, the shock 

absorber would not absorb the shock of the 

fall.

Figure 6. Rooftop of Building 161 – Rooftop 

Access and Distance to Fall Restraint System

Source: NASA OIG (July 23, 2009)
RESULTS

12 REPORT NO. IG-11-004 

These rooftop hazards were part of 47 rooftop hazards identified in a 2003 study of JPL 

by American Safety & Emergency Response.22 However, there was insufficient 

documentation for us to determine whether all of the hazards in the report had been 

adequately addressed at the time of our audit. 

Effective Inspection Process Should Identify and Prevent Hazards

An effective hazard control program should include an inspection process that identifies 

hazards in the workplace. Periodic inspections should identify existing or potential 

hazards and provide strategies to eliminate or control them. Construction Safety Group 

members are tasked with conducting inspections routinely for construction-related work 

as well as inspections of employee-reported unsafe and unhealthful conditions. However, 

we found that this inspection process was inadequate. 

Flight Projects Center Construction Inspections Were Inconsistent. We found that

safety representatives performed their inspections inconsistently and sporadically. The 

Flight Projects Center was under construction from April 2007 through May 2009. 

During this 2-year period, five safety representatives and three supervisors rotated into

and out of the Construction Safety Group and inspections were not performed routinely, 

as required by JPL internal procedures: 1 inspection was performed in June 2007, 1 in 

October 2007, and 47 between November 2007 and April 2008. There was no record of 

any other site visits until July 2008, and inspections of the site after July 2008 were 

recorded as part of inspectors’ daily JPL-wide construction site visits.

In addition, the inspectors did not follow a consistent practice of recording and following 

up on inspection results. JPL’s internal procedures require inspectors to use a 

standardized checklist to ensure all safety concerns are addressed. However, only 9 of 

the 49 inspections of the Flight Projects Center were documented on this checklist. 

Although the remaining inspection records contained pictures and written descriptions of 

noted safety concerns, without the checklists there was no assurance that all relevant 

areas had been inspected. In addition, recording inspection results on a uniform checklist 

provides a mechanism for accumulating data in a consistent manner so that recurring acts 

and conditions can be identified. 

We also found that there was no consistent practice for resolving unsafe conditions that 

the inspectors noted. We found that after inspection results were provided to Caltech 

personnel, there was no follow-up process to track and obtain resolution of the noted 

conditions. As a result, JPL and NASA had no assurance that the subcontractor was 

notified of the inspection results or took steps to abate the unsafe conditions. This lack of 

follow-up minimized the effectiveness of the inspection process. 

 

22 Assessment of Building Rooftops for Fall Protection and Fall Protection Systems Phases I & II, Contract 

#1252375, as prepared by American Safety & Emergency Response, conducted June–November 2003. 
RESULTS

REPORT NO. IG-11-004 13

The JPL Occupational Safety Office Did Not Consistently Perform Objective 

Assessments of Employee-Reported Safety Hazards. We determined that the actions 

the JPL Occupational Safety Office took in response to employee-reported incidents of 

unsafe acts were not in accordance with NPR 8715.1 requirements and that the 

Occupational Safety Office did not consistently inform the reporting employees that the 

unsafe acts or conditions had been addressed. The NPR requires Centers to conduct 

inspections as soon as possible but no later than 3 days after notification of serious 

conditions or 20 days after notification of less serious conditions. The NPR defines a 

serious condition as a hazard, violation, or condition for which there is a substantial 

probability that death or serious physical harm could result. The NPR also requires the

use of a risk assessment process to analyze and classify overall risk potential, abate and 

report those conditions that were abated within 30 days, prepare abatement plans for 

those conditions requiring more 

than 30 days to correct, and 

establish a closed-loop process to

provide assurance to the reporting 

employees that the unsafe act or 

condition was successfully 

mitigated.

For example, the JPL Occupational 

Safety Office received two reports 

from employees that an overhead 

construction crane extended into

pedestrian and vehicle traffic in 

2008. In response to these reports, 

the Occupational Safety Office

raised the matter with the 

subcontractor, which claimed that it

was unsure whether the crane was 

physically able to extend over the 

road and sidewalk and that in any 

event the crane was not carrying a 

load at the time of the report. Based 

on the subcontractor’s response, the 

JPL Occupational Safety Office

discounted the employees’ reports as 

a “perception issue.” In reaching this 

conclusion, the JPL Occupational 

Safety Office did not record any 

objective investigation that would 

validate the subcontractor’s 

explanation regarding the length of 

the crane’s extension or assess whether the crane arm itself, even in the absence of a load,

was a potential hazard to pedestrian and vehicle traffic.

Figure 7. Crane Operations

Source: Undated photo provided anonymously by a JPL 

employee in May 2009. 

Note: For purposes of illustration, the crane cable is colored 

green, while the red line shows that the load was directly 

above roadway.
RESULTS

14 REPORT NO. IG-11-004 

A JPL employee provided the NASA OIG with a photograph (see Figure 7) that showed 

the crane extending beyond the construction site into the road and sidewalk. However, 

the JPL Occupational Safety Office took no steps to investigate the matter beyond 

speaking with the subcontractor operating the crane. In our judgment, the JPL 

Occupational Safety Office’s dismissal of the employees’ concerns without further

inspection left a potential hazard unmitigated and served to discourage employees from 

reporting unsafe and hazardous conditions in the future. 

Employee-Reported Incidents and Inspection Findings Were Not Prioritized and 

Properly Addressed. NPR 8715.1 requirements are designed to ensure that safety 

resources address unsafe conditions and hazards reported by employees. Once potential 

hazards have been brought to the attention of the safety office, they are required to be 

assessed commensurate with their degree of risk. Risk is determined by assessing the 

severity of the hazard and the likelihood of occurrence. NPR 8715.1 states that imminent 

hazardous conditions (the highest degree of risk) must be addressed within 24 hours, 

serious conditions within 3 working days, and less than serious conditions within 

20 working days of being reported. We found that in the majority of cases, JPL 

addressed all reported hazards as though they were of equal risk. For example, we 

reviewed the 95 unsafe or unhealthful incidents reported by JPL employees from 

October 1, 2007, through July 9, 2009, and found that in only 2 instances was there any 

evidence that the JPL Occupational Safety Office had conducted any kind of risk 

assessment or hazard prioritization. Further, of those 95 reported incidents, only 

7 showed that the Office had conducted additional inspections to ensure that the hazard 

was abated and only 8 showed that the office had provided follow-up information to the 

reporting employees affected by the reported hazard. In the absence of an effective risk 

management process, the JPL Occupational Safety Office cannot ensure that reported 

safety hazards are assessed and addressed in a timely and effective manner. 

Employee Turnover and Insufficient Training Contributed to the 

Inspection Deficiencies

High employee turnover within the Construction Safety Group resulted in the loss of 

project knowledge. In addition, safety representatives did not receive sufficient training 

to educate them in identifying and abating the types of hazards typically found during 

construction projects. 

Since October 2006, three Construction Safety Group supervisors have been reassigned 

to other groups. The duration of the tenures of these supervisors ranged from 6 to 17 

months. During construction of the Flight Projects Center, five different safety 

representatives were assigned to the project, with the length of their assignments ranging 

from 2 weeks to 12 months. In our judgment, the short duration of these assignments

contributed to deficiencies in the JPL Occupational Safety Office’s inspection program 

because the safety representatives were provided inconsistent direction and possessed 

varying levels of expertise. 
RESULTS

REPORT NO. IG-11-004 15

Moreover, Construction Safety Group members received minimal training related to 

construction safety. We reviewed the training records of the four most recent 

construction safety representatives. Collectively, they received about 600 hours of 

training, half of which was safety-related. However, only two of their courses were 

construction-related and neither appeared to be training specifically designed to educate 

safety professionals in identifying and abating the types of hazards typically found during 

construction projects.23

Recommendations, Management’s Response, and Evaluation of 

Management’s Response

Recommendation 2. We recommended that the JPL Occupational Safety Program Office

Manager implement a standardized safety inspection process that meets JPL Internal 

Standard Operating Procedures and NASA Procedural Requirements for construction safety. 

Management’s Response. JPL management responded with comments provided by the 

Manager of the Finance and Contract Management Division. JPL partially disagreed 

with the findings that led to our recommendation, stating that the safety inspections 

performed during construction of the Flight Projects Center were consistent with 

applicable guidelines and that inspections by the JPL Occupational Safety Office were 

augmented by subcontractor inspections. Nevertheless, JPL agreed to take corrective 

action, stating that it would reassess its compliance with its internal operating procedures 

and reinstitute use of the standardized checklist to document inspections and deficiencies 

and track unsafe conditions. Management expects to complete the proposed actions by 

December 30, 2010. 

Evaluation of Management’s Response. As discussed in our report, we found no 

standardized method to document safety deficiencies. In addition, the frequency of the 

inspections performed as well as how the deficiencies were documented varied with each 

inspector. JPL’s internal procedures require inspectors to use a standardized checklist to 

ensure all safety concerns are addressed. However, only 9 of the 49 inspections we 

reviewed were documented using this checklist. In addition, we found that JPL had no 

formal follow-up process to track and obtain resolution of unsafe conditions. As a result, 

JPL could not provide assurance that deficiencies were always communicated to the 

subcontractor or that the subcontractor had taken appropriate steps to abate unsafe 

conditions. 

Although we do not agree with JPL management’s factual assertions, we find the 

proposed actions to be responsive to our recommendation and therefore consider the 

recommendation to be resolved. We will close the recommendation upon completion and 

verification of the proposed corrective actions. 

 

23 For example, the inspectors could have taken courses offered by the OSHA Training Institute such as 

Cranes and Rigging Safety for Construction; Excavation, Trenching and Soil Mechanics; Concrete, 

Forms, and Shoring; Principles of Scaffolding; and Fall Arrest Systems.
RESULTS

16 REPORT NO. IG-11-004 

Recommendation 3. We recommended that the JPL Occupational Safety Program Office 

Manager implement procedures that will improve internal oversight for reviewing 

subcontractor safety plans, engineering design drawings, and conducting final inspections. 

Management’s Response. JPL management partially disagreed with the findings that 

led to this recommendation but agreed to take corrective action. JPL agreed that the 

construction of Building 224 was noncompliant with California OSHA regulations and 

that the fall protection system was not installed in accordance with the manufacturer’s 

recommendations. However, JPL insisted that it provided consistent oversight of 

subcontractor safety plans and engineering drawings and that the JPL Occupational 

Safety Office was not responsible for the installation methods or specifications of the 

rooftop fall restraint and arrest system. 

With regard to corrective action, JPL management stated that it will work more closely 

with the JPL Facilities Division and the System Safety Program Office to improve the 

oversight process for reviewing subcontractor safety plans and engineering design 

drawings and for conducting final inspections. In addition, JPL stated that design review 

procedures have been revised to improve the review process. 

Evaluation of Management’s Response. Although we disagree with JPL’s assessment 

of its oversight responsibilities, we find its proposed corrective action to be responsive to 

our recommendation. Accordingly, the recommendation is resolved and will be closed 

upon completion and verification of the proposed corrective action.

Recommendation 4. We recommended that the JPL Occupational Safety Program Office 

Manager review employee competencies and develop training requirements that ensure that 

Construction Safety Group members obtain the training necessary to gain and maintain 

professional competency. 

Management’s Response. JPL management disagreed that the Construction Safety 

Group lacked sufficient training, but nevertheless agreed to take corrective action, stating 

that it will ensure that qualified safety professionals are hired and that construction safety 

personnel receive a minimum of 100 hours of construction safety-related training and 

professional development. JPL also said that it will ensure that its employees are crosstrained and that continuous training is provided to all personnel. 

Evaluation of Management’s Response. As discussed in our report, we found that the 

four most recent construction safety representatives had collectively received about 600 

hours of training, half of which was safety-related. However, only two courses were 

construction-related and neither appeared to be training that was specifically designed to 

educate safety professionals in identifying and abating the types of hazards typically 

found during construction projects. In our judgment, the lack of specific training 

contributed to safety inspection program deficiencies.

Despite this factual disagreement, we find JPL’s proposed action to be responsive to our 

recommendation. Accordingly, the recommendation is resolved and will be closed upon 

completion and verification of the proposed corrective action.
RESULTS

REPORT NO. IG-11-004 17

THE JPL OCCUPATIONAL SAFETY OFFICE’S 

MISHAP, CLOSE CALL, AND HAZARD 

REPORTING PROCESSES ARE INEFFICIENT,

INCOMPLETE, AND UNTIMELY

We found that the JPL Occupational Safety Office did not implement an efficient 

and effective mishap, close call, and hazard reporting system in accordance with 

prime contract requirements. The JPL Occupational Safety Office’s reporting 

system involved multiple reporting processes and, therefore, did not efficiently

consolidate incident data so that recurring problems could be identified. In addition, 

because the JPL Occupational Safety Office did not identify the root causes of 

reported incidents it could not effectively recognize and apply lessons learned. 

Finally, the JPL Occupational Safety Office did not ensure that mishaps and close 

calls were properly documented and that all incident data was timely recorded in the 

NASA Incident Reporting Information System (IRIS). IRIS is the Agency-mandated 

system for reporting, recording, and tracking all NASA mishaps, close calls, and 

post-incident corrective actions. The untimely reporting of safety incidents reduces 

the effectiveness of IRIS and limits the capability of other NASA Centers to prevent 

similar hazardous conditions. 

NASA Requires Timely and Accurate Reporting of Mishaps, Close 

Calls, and Hazards

NASA reporting requirements are applicable to JPL via the contract between NASA and 

Caltech.

24 The purpose of the NASA reporting system is to report, investigate, and 

document mishaps, close calls, and previously unidentified serious workplace hazards to 

prevent recurrence of similar accidents.25 The reporting requirements specify how to 

respond to mishaps or close calls from discovery through corrective action and closure; 

contain requirements for classifying mishaps, establishing investigation authorities, and 

performing investigations; formalize notification, analysis, and reporting obligations; 

describe roles and responsibilities; provide instruction on release of information to the 

public; and specify the interaction between NASA, Federal and state occupational safety 

 

24 Relative to mishap, close calls, and hazard reporting, the contract between NASA and Caltech 

incorporated the following reporting requirements applicable to JPL. Center (to include Caltech and its 

subcontractors) reporting requirements are per NPD 8621.1H, “NASA Mishap and Close Call Reporting, 

Investigation, and Recordkeeping,” June 2, 2000, which is incorporated in accordance with contract 

clause H-7(d)(3). Employee reporting of mishap, close call, and hazards was incorporated in the prime 

contract based on requirements in NPR 8715.1, which is incorporated in accordance with contract clause 

H-27(a)(18).

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

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

property. Mishap classifications range from a Type A Mishap, which is the most severe, to a close call, 

which is the least severe.
RESULTS

18 REPORT NO. IG-11-004 

and health administrations, the National Transportation Safety Board, and other 

Government agencies. 

Reporting Process Was Inefficient, Incomplete, and Untimely 

We found that the JPL Occupational Safety Office had multiple reporting mechanisms for 

both employee and Center reporting. These multiple mechanisms made the data 

consolidation process cumbersome and the identification of recurring problems difficult. 

Employee-reported incidents of unsafe and unhealthful conditions were collected through 

five mechanisms: Safety Early Reporting System (online reporting), Safety Concerns in 

General (e-mail, telephone to JPL Occupational Safety Office staff), Immediate Mishap 

and Close Call (incident notification telephone line), Environmental Health and Safety 

Hotline (anonymous hazard reporting system), and Safety Concerns from Mishap 

Reporting System (JPL Occupational Safety Office internal tracking of safety concerns). 

Each format recorded incident data differently and with varying levels of detail.

Center reporting of mishaps and close calls was made through NASA’s IRIS, the JPL 

Mishap Reporting System, and a subcontractor database. JPL Occupational Safety Office

personnel explained that the separate mechanisms were necessary to protect the personal 

data of the individuals involved. For example, the JPL Mishap Reporting System did not 

have the capability to filter personal data before uploading information to IRIS. 

Similarly, a separate subcontractor database was developed to avoid disclosing JPL 

employee personal data to subcontractors. As a result, transfers of information from one 

reporting mechanism to another are made manually. This process allowed for the 

discretionary reporting of incident information and the potential for errors when 

transferring data from one system to another. 

The following table contains a summary of the incidents reported by subcontractors and 

JPL personnel to the JPL Occupational Safety Office that were recorded on JPL standard 

incident reporting forms during the period of October 1, 2006, through February 28, 

2009. Our review of 14 documented construction-related incidents found that only 7 

were reported to NASA in IRIS. Of these 7 reports, 4 were reported late. While 5 of the 

7 reported incidents did include lessons learned, these lessons learned were incomplete; 

that is, they did not address the root cause of the reported incident as required by 

NPR 8621.1B.26 

 

26 “NASA Procedural Requirements for Mishap and Close Call Reporting, Investigating, and 

Recordkeeping w/Change 5 (03/15/2010),” which states that the objective is “to improve safety by 

identifying what happened, where it happened, when it happened, why it happened, and what should be 

done to prevent recurrence and reduce the number and severity of mishaps.”
RESULTS

REPORT NO. IG-11-004 19

Summary of Documented Mishap and Close Call Incidents

October 1, 2006–February 28, 2009

Classification Summary Number Reported in IRIS

Recorded Lessons 

Learned in IRIS

Type B Mishap* 3 3 3

Close Call 6 3 2

Type C Mishap

Damage between $2,500

and $250,000

1 1

Type C Mishap

 Injury involving lost 

 workday

1

Minor injury 2

No injury 1

 Total 14 7 5

* Per NPR 8621.1B, Chapter 1, a Type B Mishap is an incident that results in property damage of at 

least $250,000 but less than $1 million, or occupational injury or illness resulting in permanent partial 

disability or hospitalization.

In our opinion, there would have been meaningful lessons learned from the other two 

incidents reported in IRIS because they involved employees being exposed to potentially 

dangerous situations. The JPL Occupational Safety Office made no lessons learned 

report to NASA concerning these incidents, thereby preventing the development and 

implementation of corrective actions to reduce the probability of similar mishaps at other 

NASA facilities. 

One of the reported incidents was the collapse of a trench that had not been reinforced 

with shoring during Flight Projects Center construction (see Figure 8). The collapse 

caused approximately $329,000 in damage to fiber-optic telecommunication cables, 

reducing operational networking capabilities and jeopardizing communication with Earth 

science and space exploration missions. Although JPL facility and information 

technology personnel were notified of the mishap the day after it occurred, the JPL 

Occupational Safety Office was not notified until 3 days later. In the interim, 

subcontractor employees entered the unshored trench to begin repair work, thereby being 

placed in danger from further collapse. Had the JPL Occupational Safety Office been 

notified of the incident in a timely manner, safety personnel would have had the 

opportunity to provide guidance for safe entry into the collapsed trench. 
RESULTS

20 REPORT NO. IG-11-004

Another example of inadequate reporting was a close call involving a response by the 

JPL Fire Department to a report of 

compressed gas cylinders unearthed during 

excavation operations at the Flight Projects 

Center construction site. A photograph 

provided by the subcontractor (see Figure 9)

shows JPL Fire Department employees 

working around one of the unearthed 

compressed gas cylinders without protective 

clothing or equipment.

It was later determined that two of the four 

cylinders, including the one pictured,

contained pentaborane, a highly toxic 

chemical that may ignite spontaneously if 

exposed to air.

Source: Vanir Construction Management, Inc. (July 18, 2008) Source: Occupational Safety and Health 

Administration Web site

2008 Duct Bank Collapse at JPL. Subcontractor 

employees were placed at risk during repair work. 

The trench cave-in was not reported to the JPL 

Occupational Safety Office for 3 days.

This OSHA illustration demonstrates the 

danger of laborers being buried when a 

portion of a trench wall collapses.

Figure 8. Workers in Collapsed Trench and Unprotected Job Site

Figure 9. JPL First Responders Testing One of the 

Unearthed Cylinders

Source: Vanir Construction Management, Inc. 

(October 25, 2007)
RESULTS

REPORT NO. IG-11-004 21

The JPL Occupational Safety Office did not report this close call to NASA via IRIS until 

February 2009, 16 months after the incident, and then only at the prompting of NASA 

OIG personnel. In the absence of this and similar reporting, other NASA safety officials 

were not in a position to learn from the incident or to take steps to prevent exposures to 

similar risks in the future. 

Benefits from Lessons Learned Were Not Shared 

JPL’s reporting systems did not meet the intended objective of NPR 8621.1B, 

particularly, “why it happened, and what should be done to prevent recurrence.” This 

concern was also discussed in OSMA’s March 2007 Institutional/Facilities/Operational 

(IFO) audit, which reported that many of JPL’s lessons learned did not meet the 

definition provided in NPR 8621.1B, which states that lessons learned from a mishap 

encapsulate “knowledge or understanding that is gained by experience.” We found that 

the JPL Occupational Safety Office did not adequately capture the knowledge gained 

from mishap analyses, report lessons learned from the root causes of events, or share

lessons learned with the parties involved in the construction process or with other NASA 

Centers. For example, as previously discussed, the JPL Occupational Safety Office did 

not analyze or report on the close call involving pentaborane at the Flight Projects Center 

construction site so that other NASA Centers could learn from JPL’s experience. Our 

review of the 14 mishaps and close calls reported by the Occupational Safety Office and 

subcontractors found that 7 were reported to NASA in IRIS. In order for other NASA 

Centers to benefit from the experiences and lessons learned by JPL staff, all incidents and 

lessons learned must be documented in IRIS. 

During our initial fieldwork, we found that the JPL Occupational Safety Office did not 

have a process in place to share construction-related lessons learned from other NASA 

Centers with the JPL Facilities Division and subcontractors. We identified five reports 

containing lessons learned by other Centers that would have been useful to JPL 

subcontractors. However, the JPL Occupational Safety Office failed to share this 

information with the JPL Facilities Division or subcontractors. 

As a result of our review, the JPL Occupational Safety Office implemented a process to 

share with subcontractors lessons learned that are reported by other Centers. However, 

the JPL Occupational Safety Office still has no process in place to share lessons learned 

as a result of employee-reported incidents that occur at JPL. 
RESULTS

22 REPORT NO. IG-11-004 

Recommendations, Management’s Response, and Evaluation of 

Management’s Response

Recommendation 5. We recommended that the JPL Occupational Safety Program Office 

Manager reassess the internal mishap, close call, and hazard reporting system to improve 

timeliness and completeness and ensure compliance with NPR 8715.1. 

Management’s Response. JPL management responded with comments provided by the 

Manager of the Finance and Contract Management Division. JPL management 

nonconcurred with our finding and recommendation, stating that pursuant to the JPL 

prime contract and the State of California privacy laws the JPL Occupational Safety 

Office is not permitted to share personal identifiers and medical information with NASA. 

In JPL’s opinion, it is obligated to maintain multiple reporting processes in order to meet 

NASA and California OSHA reporting requirements and the terms of the prime contract. 

Despite its disagreement, JPL stated that the JPL Occupational Safety Office is working 

with the NASA Safety Center to input mishaps, including subcontractor mishaps, directly 

into IRIS and adding filters that are specifically designed to protect personal information 

and medical data. Once the privacy concerns are addressed in IRIS, the JPL 

Occupational Safety Office said it will be able to disseminate and implement all of the 

prime contract mishap reporting requirements. JPL and NASA’s target completion date 

is the first quarter of 2011; however, JPL management stated that the date is conditional 

and may change due to the availability of funding.

Evaluation of Management’s Response. We understand that as a contractor JPL’s 

mishap reporting requirements are unique, especially in the area of privacy and the 

sharing of medical records. However, we believe that multiple reporting mechanisms 

make the data consolidation process cumbersome and the identification of recurring 

problems difficult. In addition, the manual transfer of information from one reporting 

system to another may allow for discretionary reporting of incident information or result 

in potential input errors. 

Although JPL nonconcurred with our recommendation, we find that the actions 

management is taking in concert with NASA are responsive to the intent of our 

recommendation. Accordingly, the recommendation is resolved and will be closed upon 

completion and verification of the corrective actions. 

Recommendation 6. We recommended that the JPL Occupational Safety Program Office 

Manager establish procedures for documenting and disseminating JPL’s lessons learned and 

those from other NASA Centers. 

Management’s Response. JPL management disagreed with our findings that led to this 

recommendation, stating that all Mishap-Warning-Action-Responses coming from the 

NASA Safety Center are forwarded to JPL facilities organizations for appropriate 

dissemination to subcontractors, but agreed to take corrective action to address our 
RESULTS

REPORT NO. IG-11-004 23

recommendation.27 As corrective action, JPL stated that it will trend mishaps by type, 

level, and organization and will post the results on the JPL Occupational Safety Office 

Web site for all JPL personnel to view. Lessons learned from all lost time cases and 

cases of interest will be presented at the quarterly JPL safety committee meetings. In 

addition, the Mishap-Warning-Action-Response initiated by the NASA Safety Center 

will be forwarded to the applicable organizations for dissemination. 

Evaluation of Management’s Response. Although we continue to believe that the JPL 

Occupational Safety Office process for sharing construction-related lessons learned from 

other NASA Centers with the JPL Facilities Division and JPL subcontractors was 

deficient for the reasons stated in our report, we find JPL’s proposed actions to be 

responsive to our recommendation. Accordingly, the recommendation is resolved and 

will be closed upon completion and verification of the proposed corrective actions. 

Recommendation 7. We recommended that the JPL Occupational Safety Program Office 

Manager conduct employee training to provide guidance on proper identification of root 

causes and reinforce the concept of sharing lessons learned.

Management’s Response. JPL management disagreed with our findings that led to this 

recommendation, stating that since 2007 JPL has been inputting root cause, lessons 

learned, and corrective actions from the internal JPL Mishap Reporting System into IRIS 

and that the JPL Occupational Safety Office has taken the initiative to request NASAprovided Root Cause Analysis training to better align with NASA’s terminology and 

investigation methodology. Despite this disagreement, JPL agreed to take action to 

address our recommendation. 

Evaluation of Management’s Response. We find JPL’s proposed action to be 

responsive to our recommendation. Accordingly, the recommendation is resolved and 

will be closed upon completion and verification of the proposed corrective action.

 

27 Mishap investigation authorities issue a Mishap-Warning-Action-Response (MWAR) when their 

investigations uncover hazards they want to share with the Agency. MWARs allow investigators to share 

safety-critical information before completing the final mishap investigation report. 
RESULTS

24 REPORT NO. IG-11-004 

THE NASA MANAGEMENT OFFICE AND OSMA DID 

NOT ENSURE THAT OCCUPATIONAL SAFETY 

AND HEALTH PROGRAM REQUIREMENTS 

WERE EFFECTIVELY IMPLEMENTED AT JPL

We found that the NASA Management Office did not have established policies or 

procedures to ensure that JPL had fully implemented contractually mandated safety 

requirements and that OSMA did not follow its own procedures in conducting safety 

audits of JPL. Specifically, the NASA Management Office and OSMA did not 

ensure that JPL complied with NASA safety policy and, therefore, were unable to 

provide reasonable assurance that an effective safety oversight process had been 

implemented at JPL. Consequently, the NASA Management Office and OSMA did 

not identify that the JPL Occupational Safety Office had ineffective management 

systems and controls in the area of construction safety and NASA management did 

not have the information required to make knowledgeable risk acceptance and 

mitigation decisions, which placed JPL personnel and facilities at unnecessary risk. 

Occupational Safety and Health Programmatic Requirements

According to NASA Policy Directive (NPD) 1000.3D,28 OSMA is responsible for 

“policy direction, functional oversight and assessment” for all NASA safety activities; the 

Mission Support Directorate and its subordinate division, Agency Operations, provides 

“programmatic and institutional implementation oversight at the Jet Propulsion 

Laboratory.”29 The NPD establishes a direct reporting relationship between the Mission 

Support Directorate’s Agency Operations and the NASA Management Office but does 

not specify the roles and responsibilities of the NASA Management Office. 

NPD 8700.1E, “NASA Policy for Safety and Mission Assurance,” October 28, 2008, 

states that the Center Directors are responsible for the safety and mission success of their 

activities and operations. Each Center Director designates a safety and mission assurance 

functional manager who supports the Center Director in implementing that responsibility. 

At JPL, the safety and mission assurance functional manager is a Caltech employee. 

The JPL prime contract includes NPR 8715.1, which implements NASA safety and 

health requirements at JPL. The NPR, which sets forth the requirements for NASA’s 

occupational safety and health programs, applies to (1) all NASA organizations, 

elements, entities, or individuals; (2) all NASA equipment, property, systems, and 

 

28 “The NASA Organization,” December 3, 2008, documents the NASA organization and assigns 

organizational responsibilities.

29 The NPD actually refers to the Office of Program and Institutional Integration, whose functions have 

since been assumed by the Mission Support Directorate. 
RESULTS

REPORT NO. IG-11-004 25

facilities; and (3) all phases of the life cycle of systems or facilities and establishes the 

programmatic requirements for safety and health administration, inspections and 

abatement, safety and health training, recording and reporting requirements, and the 

evaluation of Center Occupational Safety and Health Programs.30, 31, 32

JPL’s Safety Oversight Structure Is Unique among NASA Centers

JPL is a unique Center relative to the NASA organizational structure in that it is a 

federally funded research and development center owned by NASA but operated 

pursuant to contract by Caltech. Caltech operates and maintains the facility, but NASA 

retains the authority to approve funding for operating, maintaining, improving, and

performing new construction on the facility. The contractor performs work assigned in 

the prime contract and in task orders issued by the NASA Management Office 

Procurement Officer. 

The NASA Management Office is responsible for providing oversight of industrial 

safety, occupational health, industrial hygiene, medical services, environmental 

protection, fire safety, emergency preparedness, continuity of operations, and facility 

maintenance and construction. In addition, the NASA Management Office is responsible 

for ensuring adherence to appropriate Federal, state, and local standards and guidelines. 

The NASA Management Office and OSMA Can Improve Oversight 

of JPL Institutional Safety

We found that oversight by the NASA Management Office and OSMA was insufficient 

to ensure safety program compliance at JPL. First, the two offices did not collaborate on 

their respective oversight roles and the NASA Management Office failed to coordinate its 

oversight activities with OSMA’s strategic IFO audit for JPL.33 Second, the NASA 

Management Office did not develop plans or resource requirements to oversee JPL’s 

safety operations. Third, OSMA’s scheduled biennial IFO audit issued on March 19, 

2007, failed to identify the JPL Occupational Safety Office’s noncompliance with 

 

30 On March 30, 2004, NASA administratively renamed NASA Procedures and Guidelines 8715.1 as 

NPR 8715.1, “NASA Occupational Health and Safety Programs,” without substantially changing its 

requirements. Our report refers to the NASA Procedures and Guidelines as the NPR.

31 As required by Section 19 of the Occupational Safety and Health Act of 1970, as amended, and 29 C.F.R. 

Part 1960. 

32 NPR 7123.1A, 5.1.2, “NASA Systems Engineering Processes and Requirements,” January 4, 2009,

paragraph 5.1.2, states that life cycle “. . . proceeds through a capital assets life cycle in five well defined 

phases, a ‘Pre-Formulation and Proposal’ phase, progresses into a ‘Preliminary Design’ and then a 

‘Build/Construct/Fabricate’ phase, and eventually ends after ‘Operations and Maintenance’ with an 

‘Asset Disposal’ phase.” 

33 IFO audits provide independent verification that institutions, facilities, and operations are in compliance 

with applicable NASA safety requirements. 
RESULTS

26 REPORT NO. IG-11-004 

NPR 8715.1. This inadequate oversight was caused, at least in part, by the absence of 

clearly defined roles and responsibilities between the NASA Management Office and 

OSMA. For example, personnel from both offices told us during the course of our audit 

that they had not addressed the findings in OSMA’s 2007 IFO audit because they 

believed that the other office was responsible for disposition and corrective action 

verification.

Oversight by the NASA Management Office Was Insufficient

The NASA Management Office did not have a clear definition of its on-site safety 

oversight role, and we found no documented procedures that defined that role. We also 

did not find any evidence of construction site safety reviews by the NASA Management 

Office’s Health, Safety, and Environmental Manager. 

The NASA Management Office’s Health, Safety, and Environmental Manager provided 

the OIG with a list identifying five major areas that the manager alone was responsible to 

oversee: occupational safety, environmental safety, occupational health services, fire 

safety, and emergency preparedness. This list described 166 specific tasks, including 63 

in the occupational safety area, 46 in the occupational health services area, and 27 in the 

environmental safety area. However, despite this long list, the manager did not prepare 

any strategic or other type of plan prioritizing how he intended to meet his oversight 

responsibilities. In our judgment, one individual cannot adequately oversee five major 

functional areas of safety and provide reasonable assurance that the requirements of 

NPR 8715.1 are being met at JPL. In addition, the NASA Management Office did not 

have a documented policy for safety oversight procedures that defined the office’s 

oversight roles and responsibilities, had not assessed resource requirements to fulfill its 

oversight responsibilities, and had no strategic plan to oversee JPL safety activities. 

OSMA Did Not Ensure that JPL Effectively Implemented 

Contractually Mandated Safety Requirements

The Chief of OSMA is responsible for conducting IFO audits, which provide independent 

verification that institutions, facilities, and operations are in compliance with the 

applicable IFO Baseline Requirements Set.

34 The last IFO audit that OSMA conducted at 

JPL was completed in March 2007. The 2007 IFO audit found that the JPL Occupational 

Safety Office failed to effectively report mishaps and close calls; did not provide 

adequate oversight of subcontractor job hazard analyses and safety plans; and did not 

 

34 NPR 8705.6A, “Safety and Mission Assurance Audits, Reviews, and Assessments,” April 9, 2009, states 

that the Baseline Requirements Set represents a set of requirements jointly negotiated among the 

program/project, engineering community, safety and mission assurance community, and, as appropriate, 

institutional organizations. Typically, the Baseline Requirements Set represents a subset of Agency 

safety and mission assurance processes and technical and engineering performance specification 

requirements uniquely applicable to a given NASA program, project, facility, or operation.
RESULTS

REPORT NO. IG-11-004 27

have adequate staffing for all of the ongoing facilities projects. However, OSMA was 

unaware that the JPL Occupational Safety Office did not: 

• identify and monitor budget resource requirements to assess safety program 

performance;

• effectively conduct oversight and safety and health inspections for on-site 

construction projects; or 

• identify or address root causes of the deficiencies identified in the March 2007 

IFO audit report. 

Ineffective Use of IFO Audit Process 

OSMA did not follow its oversight procedures to ensure contractor compliance with 

NPR 8715.1 during the performance of the 2007 IFO audit. NPR 8715.1, Chapter 8, 

“Evaluation of Occupational Safety and Health Programs,” requires that NASA 

Headquarters perform IFO audits that include qualitative assessments of the extent to 

which the Center safety and health programs comply with NASA policy and procedures 

and the OSHA provisions set forth in Part 1960 of Title 29 of the Code of Federal 

Regulations.35 In addition, the NPR requires that the IFO audits ensure these programs 

have been effectively implemented by the Center and are consistent with recognized best 

practices. Chapter 8 also requires that Centers evaluate their safety and health programs 

annually using the OSHA baseline questionnaire, which lists the key safety program 

elements found in Part 1960 that, if not adhered to, could result in Federal OSHA 

inspectors issuing NASA a notice of violation.36 These safety program elements are also 

required by NPR 8715.1. 

We found that the IFO audit assessment of JPL’s reporting and abating of safety hazards 

and concerns did not sufficiently address NPR 8715.1, which lists 142 auditable 

requirements. However, the 2007 IFO audit covered only 9, excluding 38 of the 47 

requirements found in Chapter 2, “Safety and Health Administration.” The IFO audit 

excluded all 42 auditable requirements found in Chapter 4, “Inspection and Abatement,” 

and 53 other key topic requirements that in our judgment are essential to verifying that

Centers are compliant with NASA safety requirements. 

 

35 Basic program elements for Federal employee occupational safety and health programs are published in 

29 C.F.R. Part 1960. The purpose of NPR 8715.1 is to provide details necessary to implement the 

occupational safety and health regulations found in 29 C.F.R. Part 1960.

36 29 C.F.R. Part 1960 program elements citable by OSHA as found in Appendix A of OSHA Instruction 

FAP 01-00-003, “Federal Agency Safety and Health Programs,” May 17, 1996. The instruction was 

developed as a reference document for identifying the responsibilities associated with Federal Agency 

Inspections and Evaluations conducted by OSHA.
RESULTS

28 REPORT NO. IG-11-004 

OSMA personnel stated that they did not have the time or resources to audit all of the 

topics and used other methods in addition to the IFO audit to monitor safety compliance 

at JPL. We contend that an audit performed only once every 2 years, although 3 years 

elapsed between the two most recent IFO audits at JPL, should cover more than just nine 

auditable requirements. Moreover, had OSMA included in the audit such elements as 

qualifications of inspectors, conduct of inspections, employee reports of alleged unsafe or 

unhealthful conditions, notice of unsafe or unhealthful conditions, and abatement of 

unsafe or unhealthful conditions, OSMA most likely would have identified significant 

deficiencies in the JPL Occupational Safety Office’s inspection and documentation of 

employee complaints of such incidents. 

We also found that the resolution process for OSMA’s IFO audit was ineffective because 

it did not review JPL’s corrective action plans in a timely or sufficient manner. JPL

management issued 10 “Corrective Action Plans” to address the 2007 IFO audit findings. 

However, during the 3-year period since the report’s issuance, OSMA had not made a 

determination regarding the adequacy of these action plans. Consequently, the audit 

findings remain open. In addition, we reviewed JPL’s corrective action plans and found 

that none of them, in our judgment, contained a full assessment of the identified 

deficiencies and root cause analyses, as required by the final IFO audit report.37

Ineffective Use of Annual Operating Agreements 

NASA did not use JPL’s Annual Operating Agreement (AOA) as a means to validate the 

adequacy of JPL’s safety resources. An AOA is a management plan that defines Center 

safety and health requirements and the resources required to meet those requirements. In 

addition, an AOA defines the metrics used to measure the efficacy of safety and mission 

assurance processes.

All NASA Centers are required to submit an AOA on an annual basis. Although there 

was no contractual requirement that JPL submit an AOA, JPL has submitted an AOA for 

the past 4 years. However, JPL’s AOAs did not address all of the elements requested by 

OSMA. Specifically, the FY 2009 AOA did not identify resource allocations by safety 

program requirements in terms of staffing, training, sampling, program promotion, 

technical information, and subcontracts. In addition, both NPR 8715.1 and AOA 

performance specifications require the identification of resource shortfalls and 

documentation of mitigation plans to address any shortfalls. However, the topic of 

resource shortfalls was not mentioned in JPL’s FY 2009 AOA. 

In addition, during a review of the JPL AOA, OSMA did not request or review any 

supporting documentation for JPL’s annual cost estimate and self-evaluation. OSMA 

 

37 Root cause analysis is a structured evaluation method that identifies the root causes of an undesired 

outcome and the actions required to prevent recurrence. Root cause analysis helps determine what 

happened, how it happened, and why it happened and the identification of appropriate corrective actions 

to prevent recurrence.
RESULTS

REPORT NO. IG-11-004 29

also failed to evaluate and ensure that the AOA included all of NASA’s safety 

requirements, which OSMA’s own internal work instruction requires.38 Had OSMA

performed its evaluation of the AOA in accordance with the work instruction, it most 

likely would have identified the same deficiencies we identified during the course of our 

audit, including that the JPL Occupational Safety Office had not identified resource 

shortfalls and was not developing resource requirements and prioritizing resources by 

work process. 

Recommendations, Management’s Response, and Evaluation of 

Management’s Response

Although we directed recommendations 8, 9, and 10 to the Assistant Administrator for 

Agency Operations, we find the comments submitted by the NASA Management Office to be 

responsive to those recommendations. 

Recommendation 8. We recommended that the Assistant Administrator for Agency 

Operations coordinate with the Chief of Safety and Mission Assurance to establish clear 

oversight roles and responsibilities concerning JPL, including responsibility for the review 

of audit findings. 

Management’s Response. The NASA Management Office concurred, stating that 

specific discussions will be held between the NASA Management Office and OSMA to 

clearly delineate the respective organizations’ responsibilities for the oversight of safety 

implementation and audit compliance at JPL. Management expects to complete the 

proposed action by January 31, 2011. 

Evaluation of Management’s Response. The NASA Management Office’s proposed 

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

completion and verification of the proposed corrective action.

Recommendations 9. We recommended that the Assistant Administrator for Agency 

Operations establish written safety oversight procedures defining the roles and 

responsibilities of the NASA Management Office. 

Management’s Response. The NASA Management Office concurred, stating that it will 

coordinate with OSMA to establish clear roles and responsibilities with respect to JPL 

safety oversight. Management expects to complete the proposed action by January 31, 

2011. 

Evaluation of Management’s Response. The NASA Management Office’s proposed 

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

completion and verification of the proposed corrective action.

 

38 Headquarters Office Work Instruction 8700-GB05, Rev E, “Development and Utilization of Annual 

Operating Agreements,” January 26, 2009.
RESULTS

30 REPORT NO. IG-11-004 

Recommendation 10. We recommended that the Assistant Administrator for Agency 

Operations assess the level of resources required for the NASA Management Office to meet 

its responsibilities and provide those resources. 

Management’s Response. The NASA Management Office conditionally concurred, 

stating that the implementation of this recommendation is dependent upon the results of 

the corrective actions related to recommendations 8 and 9 and upon the availability of 

additional resources from the Agency. However, the NASA Management Office expects 

to take action to implement this recommendation by March 31, 2011.

Evaluation of Management’s Response. The NASA Management Office’s proposed 

actions are responsive. The recommendation is resolved and will be closed upon 

completion and verification of the proposed corrective actions. 

Recommendation 11. We recommended that the Chief of Safety and Mission Assurance 

assess the IFO audit process and include steps to ensure JPL’s compliance with NPR 8715.1 

requirements. 

Management’s Response. OSMA disagreed with this recommendation, stating that 

requirements for IFO audits at JPL are contained in NPR 8705.6A, “Safety and Mission 

Assurance Audits, Reviews, and Assessments,” April 9, 2009, and noting that OSMA is 

responsible for the selection of auditable areas. OSMA further stated that performance of 

the IFO audit at JPL is not governed by NPR 8715.1 and that NPR 8715.1 should not 

have been included in the JPL prime contract. However, OSMA stated that it would

review NPR 8715.1, NPR 8705.6, and the JPL prime contract to determine whether 

additional clarifying modifications are appropriate. 

Evaluation of Management’s Response. OSMA’s implication that NPR 8715.1 was 

included in the current JPL prime contract by mistake is not reasonable given the level of 

review the JPL contract undergoes before its execution. Moreover, in our judgment it is 

entirely appropriate to hold JPL accountable to NPR 8715.1 because JPL is a federally 

funded research and development center wholly owned by the Federal Government. 

Further, NPR 8715.1 clearly states that it is applicable to all “Component Facilities” 

where NASA employees are located. Specifically, NPR 8715.1 requirements apply to the 

following: (1) all NASA organizations, elements, entities, or individuals; (2) all NASA 

equipment, property, systems, and facilities; and (3) all phases of the life cycle of systems 

or facilities. OSMA’s implication that the most comprehensive NASA policy on safety 

requirements was included in the JPL contract by mistake and that the requirements have

gone unenforced for the entire term of the contract does little to bolster our confidence in 

NASA’s oversight of the JPL safety program. 

OSMA also stated that the IFO audit process at JPL is governed by NPR 8705.6A and 

that the 2007 IFO audit of JPL complied with that NPR. However, we found that OSMA 

failed to comply with the requirements of that NPR in conducting and following up on 

the 2007 IFO audit at JPL. Specifically, OSMA did not conduct timely follow-up 

activities to verify implementation of effective corrective and preventive actions for 
RESULTS

REPORT NO. IG-11-004 31

Headquarters IFO safety and mission assurance audit findings. As previously explained, 

we disagree that the requirements of NPR 8715.1 do not apply to JPL and, therefore, 

stand behind our findings and recommendation with respect to the IFO audit process and 

its applicability to JPL. Accordingly, we consider OSMA’s comments to be 

nonresponsive and this recommendation to be unresolved. 

Recommendation 12. We recommended that the Chief of Safety and Mission Assurance 

review JPL’s compliance with NPR 8715.1 programmatic requirements.

Management’s Response. OSMA disagreed with this recommendation. OSMA stated

that the basis for this recommendation is NPR 8715.1 and that this document does not 

apply to contractor employees and should not be included in the JPL contract.

Evaluation of Management’s Response. As previously discussed, we maintain that

NPR 8715.1 does apply to JPL because it is applicable to NASA Headquarters and 

NASA Centers, including Component Facilities and international operations where 

NASA employees are located. Therefore, we consider OSMA’s comments to be 

nonresponsive and this recommendation to be unresolved. 

Recommendation 13. We recommended that the Chief of Safety and Mission Assurance 

coordinate with the NASA Management Office to establish a contractual requirement for 

JPL to annually submit an AOA and ensure that future AOAs are reviewed in accordance 

with the applicable work instruction. 

Management’s Response. OSMA disagreed with our recommendation and stated that 

the AOA is intended to be a tool to gain “insight” rather than an “oversight” mechanism. 

In addition, OSMA stated that the purpose of the AOA is to facilitate dialogue and 

negotiation between the Center Director and the Center Safety and Mission Assurance 

Director rather than between the Center and OSMA. OSMA also concluded that delivery 

of the AOA on a contractual basis may have a detrimental effect on open communication 

between JPL and NASA. OSMA’s comments did not address our conclusion that if 

JPL’s AOA had been adequately reviewed using OSMA’s own internal work instruction, 

the deficiencies we identified in the budget process would likely have been discovered. 

Evaluation of Management’s Response. As discussed in our report, the AOA defines 

Center safety and health requirements and the resources required to meet those 

requirements. The July 1, 2009, AOA call letter addressed to JPL provides: 

The purpose of the AOA process is to encourage and institutionalize the Center SMA 

[Safety and Mission Assurance] Management’s conduct of thorough planning to: 

1) obtain, understand, and define the customer requirements, 2) identify the SMA

processes and resources required to meet those customer requirements, and 3) define 

the metrics to be used to evaluate the efficacy and efficiency of the SMA process. 

The resulting AOA represents a contract between the Center Director and the Center 

Management that establishes the baseline of SMA implementation for the institutions, 

programs, and projects at the Center. Additionally, the completed AOA provides the 
RESULTS

32 REPORT NO. IG-11-004 

Chief, SMA, with an oversight tool to understand customer requirements at individual 

Centers and to establish a baseline to assess the effectiveness of the Center’s 

functional SMA processes.

In our judgment, the AOA can be a valuable tool to provide much needed structure and 

rigor to the JPL safety program. 

We do not consider OSMA’s comments to be responsive and therefore consider the 

recommendation to be unresolved. 
APPENDIXES

REPORT NO. IG-11-004 33

APPENDIX A 

Scope and Methodology

We performed this audit from March 2009 through September 2010 in accordance with 

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

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

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

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

our audit objectives. 

We performed work at JPL and at NASA Headquarters, Washington, D.C. We obtained, 

reviewed, and analyzed Federal, NASA, and JPL policies and procedures relating to 

safety and occupational health programs, including NASA Federal Acquisition 

Regulation Supplement 1852.223-7, 29 C.F.R. Part 1960, Title 8 Division of 

Occupational and Health California Regulations, NPR 8715.1, NPR 8715.3, NPR 8621.1, 

and JPL Rules and Internal Standard Operating Procedures. We also reviewed NASA 

contract NAS7-03001 to determine contractual requirements. 

We interviewed NASA, JPL, and subcontractor employees. We reviewed the JPL 

processes for reporting, investigating, and documenting mishaps, close calls, and hazards 

to determine whether JPL ensured that hazards were properly identified and abated and 

that lessons learned were properly communicated to prevent reoccurrence. We 

selectively reviewed subcontract procurement files and associated safety plans for 

construction projects since October 2006 to determine whether JPL had established 

oversight procedures to ensure contractor and subcontractor compliance with OSHA 

regulations and NASA policies and procedures. We also reviewed the Caltech budgetary 

process to determine whether JPL employed an adequate management system of control 

in construction safety areas to ensure resources were effectively allocated to address 

safety considerations.

To determine whether NASA provided adequate oversight of the JPL safety program, we 

interviewed officials with the NASA Management Office and OSMA. We also followed 

up on the findings of the 2007 IFO audit conducted by OSMA in support of the NASA 

Management Office. 

Use of Computer-Processed Data. We used computer-processed data to perform this 

audit. JPL mishaps and close calls were entered into IRIS. We separately requested 

documented construction-related incident reports from the JPL Occupational Safety 

Office and compared the information in the key data fields. We believe the data to be 

reliable based on our tracking and comparison.
APPENDIX A 

34 REPORT NO. IG-11-004 

Review of Internal Controls 

We reviewed and evaluated the internal controls associated with NASA oversight of the 

JPL Occupational Safety Program Office and JPL staff oversight of subcontractors 

performing on-site construction projects. We found deficiencies in both areas, as 

discussed in this report. Our recommendations, if implemented, should correct the 

weaknesses we identified. 

Prior Coverage

During the last 5 years, the NASA Office of Inspector General issued one report relevant 

to the subject of this report: “Glenn Research Center Needs to Better Define Roles and 

Responsibilities for Emergency Response” (IG-08-027, September 3, 2008), accessible 

over the Internet at http://oig.nasa.gov/audits/reports/FY08. 
APPENDIX B

REPORT NO. IG-11-004 35

MANAGEMENT COMMENTS
APPENDIX B

36 REPORT NO. IG-11-004

Omitted due 

to size (a 

copy can be 

provided on 

request).
APPENDIX B

REPORT NO. IG-11-004 37
APPENDIX B

38 REPORT NO. IG-11-004
APPENDIX B

REPORT NO. IG-11-004 39
APPENDIX B

40 REPORT NO. IG-11-004
APPENDIX B

REPORT NO. IG-11-004 41

Edited to 

differentiate 

between 

policy and 

the actual 

number of 

years 

between 

audits on 

page 28.
APPENDIX B

42 REPORT NO. IG-11-004

Changed 

“required” to 

“requested” 

on page 28.
APPENDIX B

REPORT NO. IG-11-004 43
APPENDIX C 

44 REPORT NO. IG-11-004 

REPORT DISTRIBUTION

National Aeronautics and Space Administration

Administrator

Deputy Administrator

Chief of Staff

Chief, Safety and Mission Assurance 

Assistant Administrator, Agency Operations

Director, Jet Propulsion Laboratory 

Director, NASA Management Office

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, NASA Financial Management, Office of Financial Management and 

Assurance 

Director, NASA Issues, Office of Acquisition and Sourcing Management 

Congressional Committees and Subcommittees, Chairman and 

Ranking Member

Senate Committee on Appropriations 

Subcommittee on Commerce, Justice, Science, and Related Agencies

Senate Committee on Commerce, Science, and Transportation

Subcommittee on Science and Space

Senate Committee on Homeland Security and Governmental Affairs

House Committee on Appropriations 

Subcommittee on Commerce, Justice, Science, and Related Agencies

House Committee on Oversight and Government Reform 

Subcommittee on Government Management, Organization, and Procurement 

House Committee on Science and Technology

Subcommittee on Investigations and Oversight 

Subcommittee on Space and Aeronautics
REPORT NO. IG-11-004 45

Major Contributors to the Report: 

Raymond Tolomeo, Science and Aeronautics Research Director

Ronald Yarbrough, Project Manager 

Stephen Siu, Lead Auditor 

Jiang Yun Lu, Auditor 

David Milligan, Safety and Occupational Health Specialist
DECEMBER 13, 2010

REPORT No. IG-11-004 

OFFICE OF AUDITS

OFFICE OF INSPECTOR GENERAL

ADDITIONAL COPIES

Visit http://oig.nasa.gov/audits/reports/FY11/ to obtain additional copies of this report, or contact the 

Assistant Inspector General for Audits at 202-358-1232. 

COMMENTS ON THIS REPORT

In order to help us improve the quality of our products, if you wish to comment on the quality or 

usefulness of this report, please send your comments to Mr. Laurence Hawkins, Audit Operations and 

Quality Assurance Director, at Laurence.B.Hawkins@nasa.gov or call 202-358-1543. 

SUGGESTIONS FOR FUTURE AUDITS

To suggest ideas for or to request future audits, contact the Assistant Inspector General for Audits. 

Ideas and requests can also be mailed to:

Assistant Inspector General for Audits 

NASA Headquarters

Washington, DC 20546-0001 

NASA HOTLINE

To report fraud, waste, abuse, or mismanagement, contact the NASA OIG Hotline at 800-424-9183 or 

800-535-8134 (TDD). You may also write to the NASA Inspector General, P.O. Box 23089, L’Enfant 

Plaza Station, Washington, DC 20026, or use http://oig.nasa.gov/hotline.html#form. The identity of 

each writer and caller can be kept confidential, upon request, to the extent permitted by law.