From: NASA Office of Inspector General
Posted: Friday, November 12, 2010
Final Memorandum Assessing Launch Services Program's Interim Response Team Training Requirements (Report No. IG-11-003; Assignment No. A-09-011-01) Full report
During our audit of NASA's Launch Services Program (Assignment A-09-011-00), the Office of Inspector General received an allegation that Launch Services personnel were not properly trained to investigate launch vehicle mishaps.
The Kennedy Space Center's Safety and Mission Assurance Directorate is responsible for defining the roles and responsibilities associated with mishap preparedness and contingency plans (mishap plans) for the Launch Services Program. Mishap plans, which are prepared at the Headquarters, Center, program, and project levels, describe the procedures to report, investigate, and record mishaps and close calls, to include those that occur during launch emergencies. The response team is considered "interim" because it operates on a short-term basis and concludes its mishap-response activities when the official NASA-appointed investigating authority arrives at the scene and takes control. Although launch emergencies and mishaps at Kennedy are rare, team members must be properly trained to support the initial phases of a mishap investigation.
To assess the allegation about a lack of adequate training for response team members, we reviewed training requirements for the Kennedy Interim Response Team in the relevant mishap plans (Science Mission Directorate, Exploration Systems Mission Directorate, Kennedy Space Center, and Launch Services Program). See Enclosure 1 for details on the review's scope and methodology.
While the mishap plans we reviewed appropriately identified roles and responsibilities for managing contingency actions, NASA has not established training requirements for Interim Response Team members. In addition, we found that training requirements for Interim Response Team members in the Launch Services Program's mishap plan were inconsistent with mishap plans developed by Kennedy Space Center, the Science Mission Directorate, and the Exploration Systems Mission Directorate. We also determined that none of the 16 safety and mission assurance personnel assigned as Kennedy Interim Response Team members during the Orbiting Carbon Observatory (OCO) and Lunar Reconnaissance Orbiter/Lunar Crater Observation and Sensing Satellite (LRO/LCROSS) launch missions had completed all of the required training included in the mission-specific mishap plans, and only 3 of the 16 had completed the "Introduction to Mishap Investigations" training course required by the Kennedy Mishap Plan. Consequently, we question whether personnel assigned as Interim Response Team members were sufficiently knowledgeable about the NASA mishap investigation process to effectively execute the assigned roles and responsibilities of the Interim Response Team in the event of a mishap or close call.
We provided a draft of this memorandum to the Agency on September 29, 2010, recommending that NASA's Chief of Safety and Mission Assurance develop minimum requirements for personnel assigned to Interim Response Teams and update NPR 8621.1B to reflect these requirements, and that the Director of Kennedy's Safety and Mission Assurance Directorate develop procedures to ensure that assigned personnel complete the required training.
The Chief of Safety and Mission Assurance concurred with our recommendations and stated that the Office of Safety and Mission Assurance (OSMA) will update the NPR to to include general training requirements for safety and mission assurance personnel assigned to Interim Response Teams as well as a requirement that Mishap and Contingency Plans specify additional training requirements appropriate to the hazards and tasks associated with a particular Center or program. The Chief also concurred with our recommendation that the Director of Kennedy's Safety and Mission Assurance Directorate develop procedures to ensure that personnel assigned to Interim Response Teams complete the required training. The Chief stated once NPR 8621.1 is updated, the Kennedy Safety and Mission Assurance Directorate will ensure that its process includes the updated applicable training requirements. The full text of NASA's comments is reprinted in Enclosure 2. We consider the Chief's proposed actions to be responsive to our recommendations. Therefore, the recommendations are resolved and will be closed upon verification that management has completed the corrective actions.
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