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NASA OIG: Glenn Research Center Needs to Better Define Roles and Responsibilities for Emergency Response

Status Report From: NASA Office of Inspector General
Posted: Thursday, September 4, 2008

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OVERVIEW

The Issue

This review was initiated in response to two hotline complaints concerning the Glenn Research Center at Lewis Field: the first concerned laboratory safety and the review process for granting safety permits, and the second concerned first responders and their actions during a January 2006 fire in a Glenn underground tunnel. Our report, "Effective Inspection Program Key to Improving Laboratory Safety at Glenn Research Center" (IG-07-032, September 24, 2007), addressed laboratory safety and the process for reviewing, approving, and maintaining safety permits for Glenn laboratory operations. This report addresses the response to Glenn emergencies.

The primary goal of an emergency response system is to mitigate the harmful effects of an emergency by preventing loss of life, serious injury, and damage to property or the environment. Federal requirements for emergency response are contained in Homeland Security Presidential Directive (HSPD)-5, "Management of Domestic Incidents," February 28, 2003. HSPD-5 establishes general emergency response requirements for all Federal agencies and requires that Federal agencies develop and administer the National Incident Management System (NIMS). NIMS provides a consistent Nation-wide template to enable all government, private sector, and nongovernmental organizations to work together during domestic incidents and includes the implementation of an Incident Command System (ICS) during each emergency response. ICS is a standard, on-scene, all-hazards incident management system that applies to firefighters, law enforcement personnel, hazardous materials teams, rescuers, and emergency medical teams. ICS is designed to facilitate the work of cross-functional teams in a smooth, coordinated effort under a single management system. This enables responders to effectively work together in preparing for, preventing, responding to, and recovering from emergencies.

At Glenn, the organizations responsible for emergency response include the Office of Security Management and Safeguards; the Safety and Mission Assurance Directorate; and the municipalities of Brook Park, Ohio, and Fairview Park, Ohio. The Glenn Emergency Management Coordinator is assigned to the Office of Security Management and Safeguards and is responsible for preparing the Glenn Emergency Preparedness Plan (EPP). The Glenn EPP requires that emergency responders comply with ICS during all Center emergencies.

We reviewed the management of Glenn's emergency response system and its adherence to Federal and NASA guidance. We analyzed the actions taken by Glenn responders during 10 of the 572 emergencies experienced at Glenn during fiscal years (FYs) 2005 through 2007. The details of our review's scope and methodology are in Appendix A.

Results

The lack of clearly defined roles, responsibilities, and lines of authority for Glenn responders, along with the absence of memorandums of understanding (MOU) with off- site responding organizations, has negatively affected the Center's ability to implement ICS and respond effectively to emergencies. When ICS is not properly implemented during an emergency, the chain of command and lines of communication can become confused, increasing the risk of injury for responders and other personnel, as well as increasing the risk of damage to NASA assets. For at least two of the emergencies that we reviewed, that confusion could have resulted in serious injury to the responders and further damage to Glenn assets.

We found that the Glenn first responders failed to adequately implement ICS during each of the 10 emergencies that we reviewed. Specifically, Glenn emergency responders

  • did not keep a safe distance from the emergency scene or adequately assess the nature of the emergency (2 out of 10);
  • did not initiate an emergency notification protocol based on the severity and type of emergency (5 out of 10);
  • failed to isolate and deny entry into areas "immediately dangerous to life and health"1 (3 out of 10);
  • allowed personnel to enter hazardous environments without appropriate respiratory protection (2 out of 10);
  • failed to provide critical institutional information to responding fire departments (4 out of 10); and
  • failed to ensure that all reports related to the emergency response contained accurate and consistent information (10 out of 10).

Although the EPP required Glenn emergency responders to implement ICS when responding to emergencies, it did not clearly define the roles, responsibilities, authority, and limitations for each of the responders and responding organizations under ICS. In addition, Glenn did not have MOUs with local police, fire, and rescue departments designating how they should coordinate and integrate with the Glenn responders during an emergency. Glenn's ability to respond effectively to on-site emergencies is contingent on the mobilization and use of resources from multiple and diverse response organizations. When properly implemented, ICS provides a management system that allows these resources to be effectively managed and integrated.

Management Action

To improve the effectiveness of Glenn's emergency response system, we recommended that the Chief, Office of Security Management and Safeguards, review the roles and responsibilities assigned to each of the responding organizations and ensure that the responders are qualified to assume those roles and responsibilities and can effectively and timely respond to Glenn emergencies. Once the review is completed, the Chief, Office of Security Management and Safeguards, should revise the EPP, if necessary, based on the results of the review. We also recommended that the Chief, Office of Security Management and Safeguards, revise the EPP to require that each Glenn organization with an emergency response role develop standard operating procedures detailing the specific responsibilities for their respective responder personnel. To ensure that the standard operating procedures complement the EPP and do not provide contradictory information, we recommended that the EPP be revised to require the Glenn Emergency Management Coordinator to review and approve the standard operating procedures before implementation. We also recommended that the EPP require the Emergency Management Coordinator to reconcile all emergency response reports filed, to include those by off-site responding organizations, to ensure that the reports are accurate and consistent. Finally, we recommended that the Glenn Director establish MOUs with all non-NASA organizations that respond to emergencies at the Center. The Emergency Management Coordinator should participate in developing those MOUs.

In a response to a draft of this report, the Glenn Director concurred with our recommendations and described actions to be taken by the Center to improve the effectiveness of Glenn's emergency response system. First, the Glenn Emergency Management Coordinator will review the roles and responsibilities of on-site and off-site emergency responders by November 30, 2009. Second, the Chief, Office of Security Management and Safeguards, in conjunction with the Director of Center Operations, the Director of Safety and Mission Assurance, and the Emergency Management Coordinator will analyze and determine the best organization for emergency response and incorporate the results into the Center EPP by July 30, 2009. Third, the Emergency Management Coordinator, in cooperation with the Chief, Security Management and Safeguards Office; Chief, Safety, Health, and Environmental Division; the Office of Chief Counsel; and the Center Director's Office, will initiate negotiations to establish MOUs with adjoining or jurisdictional organizations that provide fire suppression, fire rescue, emergency medical services, police, and hazardous chemicals and materials response by December 10, 2009. Fourth, the Safety, Health, and Environmental Division will develop a new emergency action plan for each facility at Glenn by April 23, 2009. (See Appendix B for the full text of management's comments.)

Within the period of the audit, Glenn instituted the use of the ICS and implemented an aggressive training effort to upgrade the credentials of emergency responders. Glenn indicated in their response that they have met and exceeded all NASA required NIMS training by training 114 individuals, with seven of the 114 trained to ICS 300 level and five of the 114 trained to the ICS 400 level.

We consider management's proposed actions to be responsive. The recommendations are resolved and will be closed following verification that all actions have been completed.

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