Inspector General's Letter to Congress Concerning the
Shuttle-Mir Program
National Aeronautics and
Space Administration
Headquarters
Washington, DC 20546-0001
Office of Inspector General
August 29, 1997
The Honorable F. James Sensenbrenner
U.S. House of Representatives
Chairman, Committee on Science
Suite 2320 Rayburn House Office Building
Washington, DC 20515-6301
Dear Mr. Chairman:
On July 11, 1997, you requested the NASA Office of Inspector General to assess NASA's participation in the Russian Mir Space Station Program. Specifically, you asked my office to analyze: (1) suitability of Russia's Mir space station for habitation by U.S. astronauts, (2) research productivity on board the Mir, and (3) cost effectiveness of continued NASA involvement in the Mir space station program. The Agency must address these same issues.
NASA balances three major factors in its assessment of the risks/benefits of continued astronaut participation in Mir. First, it evaluates the dangers posed by changing conditions aboard the Mir. As Dan Goldin stated, "Mir is an aging spacecraft that has long exceeded its original design life and is exhibiting an increasing number of in-flight anomalies." Second, it considers the impact on American-Russian relations far broader than NASA's science and technology goals. (The Mir program is also a "critical underpinning of the success of the U.S./Russian Joint Commission on Economic and Technologic Cooperation.) Third, it assesses how participation in Mir activities impacts the Shuttle manifest. (The Agency has established a minimum number of six flights as being essential to fly the Shuttle safely. Down time effects the proficiency of the workforce that maintains Shuttle operations.)
The Agency has instituted three processes to conduct its risk/benefit assessment. Astronaut Frank Culbertson, the NASA Shuttle-Mir Program Manager, conducts internal safety reviews. The NASA Associate Administrator for Safety and Mission Assurance also conducts safety reviews. Lieutenant General Tom Stafford, a former astronaut, leads an external team that reviews safety and operational readiness. (For more detail on the Stafford assessment team, refer to Appendix A.) We did not evaluate the effectiveness of these mechanisms. However, various sources have voiced their concern about the objectivity and/or adequacy of NASA's risk/benefit assessment process in the face of stated national policy to maintain the Russian/ American partnership. Among others, concern was articulated by Charles S. Harlan, the former Director, Safety, Reliability and Quality Assurance, Johnson Space Center. The concerns of this former NASA official are set forth in Appendix B (Letter from Harlan to Gregory, dated June 29, 1997).
We are aware that the Russians have successfully surmounted serious problems on the Mir (See Appendix C). Nevertheless, ongoing problems on the Mir are occurring at a time when the Russian government may not be in a position to provide adequate financial and technical support to enable the aging space station to operate safely. Moreover, these problems are exacerbated by the Russians' failure to timely or fully communicate with NASA. Without knowledge of the problems on Mir or its operating systems, NASA cannot fully prepare our astronauts for their mission.
At this juncture, because of obvious time constraints, I have no definitive answers to the issues you posed to my office. However, recent events on the Mir (e.g., the fire on February 23, 1997, and a computer failure during the August 18, 1997, Progress docking with Mir) have heightened concerns about NASA's continued involvement in Mir space missions. Thus, I am forwarding to you a brief overview of some of the risk areas which the Agency must assess against the benefits it hopes to achieve. (See Appendix D for a summary list of risk areas identified by the Office of Inspector General.)
I. BACKGROUND
A. The International Space Station (ISS) Program
In the late 1980's, the United States began negotiations with Russia to form a space exploration partnership. A decade of negotiations with Russia and other countries ultimately led to the ISS Program. The ISS Program has three main phases.
Phase I (1994-1997) began in February 1994, when Cosmonaut Sergei Krikalev became the first Russian to fly on board the Space Shuttle. The first U.S. astronaut to participate in Phase I assignments to Mir was Dr. Norman Thagard, who began a 115-day mission aboard Mir in March 1995. Since then, 4 U.S. astronauts (Dr. Shannon Lucid, John Blaha, Dr. Jerry Linenger, and Dr. Michael Foale) have had extended assignments ranging from 3 to 6 months on board Mir. In September 1997, the sixth U.S. astronaut (Dr. David Wolf) is scheduled to begin his stay on Mir.
Phase II (1997-1999) will be the assembly and placement of a core space station using U.S. and Russian parts. Phase II will also establish a three-person crew capability and an initial U.S. laboratory environment for science and technology activities. This phase will schedule seven U.S., two Russian, and one joint assembly flight. This process begins with a launch of the Russian Proton Rocket carrying the station's automated spacecraft known by its Russian acronym, FGB. The FGB will provide attitude control and propulsion during early station assembly. Phase II concludes with the delivery of the Airlock on STS-100.
Phase III (1999-2002) will launch 13 U.S., 8 Russian, 2 European, 1 Japanese, and 2 Japanese/ American assembly flights beginning in October 1999. It concludes with the delivery and activation of the U.S. Habitation Module. Initially, astronauts will work in the U.S. laboratory module for at least 2 weeks while a docked Shuttle orbiter provides assured return-to-Earth capability. This phase includes the delivery of U.S. payload racks to start science and tech- nology research. Also, during Phase III, four solar array panels will be added to the Russian power/control mast to provide additional power. The Japanese Experiment Module (JEM) will also be delivered during Phase III. (See Appendix E for more information about the ISS program.)
B. Early Results from Phase I: Thagard, Lucid, Blaha
Thagard, Lucid and Blaha, who experienced no life-threatening incidents during their stay on Mir, each offered suggestions to improve the ISS program. For example, Thagard commented that conducting science experiments would be easier if there were better space-to-ground communications with the Principle Investigator (PI). Blaha observed that the daily scheduling of crew activities should be moved from the ground support to the crew because the crew had a better feel for the workload and time requirements to perform tasks. Lucid and Blaha also commented on the problems associated with the accumulation of trash and other materials, storage, and disposal, particularly wet trash because of its bulk. They emphasized the need for inventory and storage systems on the Mir and ISS so that the crew could readily locate items. Thagard, Lucid, and Blaha all agreed that better proficiency in the Russian language is necessary for safe operations on the Mir. They all agreed that language proficiencies should be improved for all crew members aboard the ISS. Dr. Thagard stated that English should be the only language for system procedures on the ISS. All three astronauts consistently praised the cosmonauts for their inventiveness and ability to cope with the constant maintenance requirements of the aging space station (See Appendix F, Testimony of Dan Goldin, before the Science Subcommittee, June 18, 1997, for other positive aspects of the U.S./Russian ISS partnership.
II. MAJOR RISKS ASSOCIATED WITH PHASE I
Recently, two life-threatening incidents occurred on board the Mir - a fire in February 1997, and the Progress collision in June. Another mishap occurred in August when the main onboard computer failed during a Progress docking which caused a loss of attitude control. This resulted in a major powering down of Mir. Of the major mishaps since February 1997, the collision of the Progress vehicle with the Spektr module may have the most serious consequences to the planned American science and research activities - the Spektr module contained most of the U.S. materials and supplies related to scheduled experiments and other research activities. Since the collision, Spektr has been sealed. The extent of damage to U.S. equipment within the module is unknown.
In addition to these obvious "red flags," there are other serious problems associated with the Russian's aging space station which pose risks to the Mir crew. We discuss some of these below.
A. Soyuz As A Rescue Vehicle
A Soyuz-TM spacecraft, which carries a maximum of three passengers, is docked with the Mir at all times to provide the Mir crew with a "life boat". (Two Soyuz spacecraft are docked with Mir during periods of crew transition, one of which departs for Earth with the returning crew.) The Soyuz also serves as a temporary "safe haven" for the crew during periods of less than optimal life support. (The Soyuz was used in this capacity directly after the Progress-Mir collision on June 25, 1997, and again on July 16, 1997, when a crew member disconnected a power cable.) Additionally, the Soyuz has been used to orient the Mir's solar array panels. The Soyuz Reaction Control System (RCS) was directly employed to perform this operation. Depending on the duration and extent of the activity, Soyuz expends varying amounts of fuel. Such auxiliary uses of Soyuz may increase the likelihood of a system failure or, in the case of the RCS, reduce the amount of fuel available for an emergency re-entry.
The most recent Soyuz re-entry on August 14, 1997, raises additional concerns about the condition of the Soyuz. The re-entry ended with a rough landing when power jets failed to slow down the spacecraft before impact. One of the cosmonauts commented that if a third passenger had been seated in the Soyuz's right-side, that crew member would have sustained injury.
If an emergency arises in which only our astronaut can return on the Soyuz, the astronaut would have difficulty operating the vehicle. Our astronauts are trained by the Russians as passengers, not as pilots. A NASA official questioned his Russian counterpart whether Dr. Foale could fly Soyuz should an emergency evacuation of Mir be required (in the context of the August 22, 1997, Interval Vehicle Activity (IVA)). The RSA official responded that, should the need arise, Foale would receive instructions via the Soyuz communication system. However, without some familiarity with Soyuz operations, astronauts are at extreme risk if it becomes necessary to manually manipulate controls based on instructions from ground control. This risk is very real, as illustrated by an anecdote Shannon Lucid reported during a debriefing. She stated:
A cosmonaut in Star City told me that the Soyuz was built by engineers and these engineers never asked for any input from the people that were actually going to use it. One example is that there is a little switch that is under the Soyuz panel. The board engineer's knees are underneath the Soyuz panel. This switch is extremely important. It is very, very tiny, but it is very, very important it is used during a depressurization. The switch has three letters, or Russian identifiers. What absolutely blew my mind, concerning this switch, was that during an extra briefing in the Soyuz someone just happened to mention another switch. This other switch had the very same three letters and it was made exactly the same size as the depressurization switch and it was close to the same location. But this switch had an entirely different function. It would be used if, I think this is right, if you had something wrong with the parachute deployment upon landing. This is a totally different function, but it is almost in the same place as the other switch. You could also hardly find these switches. I just found that unbelievable.
One astronaut stated that he/she was not prepared to fly Soyuz home alone should the need arise. Moreover, some individuals interviewed stated they did not believe one person could fly the Soyuz independently.
B. Fire Hazards
Fire aboard the Mir, or any spacecraft, is a life-threatening event. On February 23, 1997, the Solid Fuel Oxygen Generator (SFOG) canister in Kvant-1 began to burn uncontrollably with a blowtorch-like, white, conical flame from 1 foot to 4 feet in length. 5 The flame was described as containing molten metal and sparks and reached a temperature of approximately 900 degrees Fahrenheit.
When the fire occurred, there were two Soyuz vehicles docked on Mir, each equipped to carry up to three crew members from the station. However, all six crew members were on one side of the fire with access to only one Soyuz vehicle. If the fire had become uncontrollable and evacuation necessary, it would have been difficult for three crew members to get around the fire to the other Soyuz.
All fire response equipment, including emergency instructions, gas and particulate masks, extinguishers, emergency ventilators and oxygen sources, and first aid supplies should be clearly marked, in ample supply, and readily accessible. These conditions did not exist at the time of the fire which occurred during Linenger's flight. 6 Equally important, all crew must be thoroughly trained on all fire response equipment and procedures, and be able to communicate and be understood instantly by other crew members and ground control. An astronaut also suggested that distinct alarms need to sound throughout the station's modules when catastrophic events occur.
Although the fire which occurred on February 23, 1997, appears to be an isolated incident, it is important to determine its cause and take corrective actions. There are discrepancies between Linenger's report and what the Russians are reporting. These discrepancies need to be resolved since the canisters continue to be used as an oxygen generating system for Mir. (See Appendix H for a discussion on the discrepancy in the accounts of the fire.)
C. Problems With Oxygen Generation and Carbon Dioxide Removal
Over the years, there have been problems with oxygen generation and carbon dioxide removal on the Mir. The primary source of oxygen supply has been the Elektron oxygen generator. Carbon dioxide is removed from the air by a Vozdukh scrubber unit. On several occasions, these primary sources of life support systems have had to be shut down or have experienced failures. However, the SFOG canisters have been available to back up the Elektron and the lithium hydroxide (LiOH) units have been a backup to the Vozdukh scrubber.
Ulf Merbold, the German astronaut who spent 30 days on board the Mir in 1994, noted that the oxygen supply and carbon dioxide scrubber units were old and required considerable maintenance. U.S. astronauts also noted problems with the primary units. Astronaut Thagard, in the ECLSS Debrief Minutes, noted that the Elektron ". . . system had to be turned on and off for power considerations . . . ." Thagard went on to note ". . . on most days in the month of May and even in June . . . " SFOG candles were used instead of the Elektron. Astronaut Shannon Lucid, during her stay on Mir, noticed side effects of increased levels of carbon dioxide, including decreased mental concentration. In her October 15, 1996, Flight Crew Systems Division Post Flight Debrief, she replied as follows:
1. Did you notice any changes in your performance due to the long duration mission? Specifically sensory capabilities such as vision, olfaction, muscular deconditioning, ability to perform science or concentrating on tasks for a long period of time? If you did, what as the most bothersome of the effects that you encountered?
I am a single data point and all I can comment on is my perception of things. I didn't notice any change in taste, smell, vision, or anything else. I felt the same as I always did. However, I could tell when the CO2 concen-tration was going up. When the CO2 concentration was getting too high, it was a little harder to think. It was easier to make mistakes.
2. Would this be similar to breathing thin air?
No, it seemed that I would yawn a lot. It is hard to explain, I could sense when the CO2 concentration was going up.
3. Would the CO2 concentration go up because some automatic process was not working correctly?
There were many reasons that could cause the CO2 concentration to go up. The CO2 level would go up when the life support system wasn't working as well as it should and when there was a lot of crew members exercising at the same time. I could tell when the CO2 was getting higher, and the rising CO2 levels definitely increased the crew's chances for making mistakes.
4. How long did it usually take to get the CO2 levels back down in the base block?
It depended. Sometimes, we would leave the base block and use a small fan to blow the CO2 out. We would vacate the base block for an hour or so trying to get the CO2 levels back down.
The primary sources of oxygen and CO2 removal require electrical power supply. Since the Progress collision, the use of both systems has been minimal and interrupted. Use of the backup systems have been extensive.
D. Fatigue and Stress
The Mir crew experiences fatigue and stress during their long-duration flights. Several factors contribute to these conditions: (1) conducting constant routine maintenance and repairs, (2) performing scheduled scientific activities with poor instructions from and limited communi- cations with the PI, (3) living day-to-day in a confined environment with minimal contact with family and friends. Limited windows of communication transmission between Mir and ground control also intensifies stress and fatigue. However, as crises confront the crew, the stresses become a greater risk factor.
In June 1997, when the crew was experiencing difficulty in identifying the origin of the Kvant-1 coolant loop leak, the cosmonaut commander repeatedly argued with ground control and showed considerable irritation. The commander also indicated that he believed that ground control did not take his concerns seriously or misinterpreted his statements. Stress and fatigue were also key factors explaining why a crew member disconnected a cable on July 16, 1997, causing the Mir to lose power and drift. An American engineer familiar with recent events aboard the Mir believes fatigue to be the probable cause of the crew's inadver- tently closing a valve that interrupted coolant flow to the Elektron thereby causing it to overheat.
E. Training
The Russians are responsible for their space station. Therefore, U.S. astronauts receive limited training for repairs. The Mir, however, is an aging system and serious anomalies are occurring. If we are to continue participation in the program, our astronauts need training in maintenance and emergency repairs. Other astronaut debriefings indicate that American Mir crew members feel they are not properly cross-trained. Astronauts on Mir missions have also raised concerns about training received on American scientific activities. These problems are exacerbated by inadequate procedural guidance, a lack of access to PI's, and related in-orbit instruction from ground support.
NASA staff visiting and participating in Russian-based training have observed that mockup training equipment lacked fidelity; i.e., realistic simulation. This could jeopardize the success of scientific efforts on board Mir. Additionally, training in support of research activities has been termed as a low priority at Star City and the Korolev Energia, formerly known as the NPO Energia, site. Indeed, a review of training-related observations made by NASA staff indicated that comprehensive coordination of Mir training is needed to overcome such general problems as inadequate training equipment, unavailability of expert staff (e.g., American PI's are not present at Russian training facilities), varying capabilities of Russian training staff, scheduling difficulties, and inadequate training documentation and materials.
F. U.S./Russian Communications
During Phase I, there have been problems in the coordination, timeliness, and completeness of communications between the Russian Mission Control Center (MCC) and the NASA Houston MCC. These problems became evident at the time of the fire on Mir on February 23. The Moscow MCC did not inform the Houston MCC about the fire until after the incident.
The general feeling held by NASA program management is that since the February fire on board Mir, communications between the two nations is much more open and coordination has significantly improved. Nevertheless, on August 22, 1997, the Russians unilaterally changed the cosmonaut assignment for conducting the IVA even though that activity also affected the safety of the American crew member.
NASA has made several observations and recommendations concerning communications. Among these observations and recommendations are the following:
". . . There is minimal horizontal information flow within or between organizations on the Russian side. When you provide information to an individual, do not expect that anyone other than that person will receive it. . ."
". . . Russian culture requires long term relationship between US[sic] and Russian counterparts to have effective communication. . ."
". . . Identify and communicate reporting procedures to management, such as daily status reports before the mission. Make an agreement on how reporting will be handled and stick to it. . ."
(See Appendix I, U.S./Russian Flight Research Program "Lessons Learned Phase 1A Mir Operations").
In their debriefing sessions, astronauts voiced their dissatisfaction with communications between the crew members on the station and ground support. For example, the flight support group was worried that Dr. Linenger and Vasily Tsibliev were not getting along. According to Linenger, this was untrue. But, it was the impression the MCC's had because of Mir communications. 13 One of the major problems Dr. Lucid identified was "big echoes" in the communications, especially when two-way links were established. She said, "It was practically impossible to listen and hear what the other person was saying during the two-way video."
The lack of continuous communications between the station and ground support also affected the ongoing science experiments. Astronaut Blaha, in his debriefing, stated that experiments could have been facilitated by better station-to-ground communications that included the PI. The crew member doing the experiment and the responsible PI need to discuss various aspects of the experiment in real time rather than having to wait until a post-flight debriefing. Many times, however, the crew would have to wait until the Mir was in daylight so the solar array panels could provide power to the communications equipment.
G. Ethylene Glycol Exposure
Ethylene glycol is a clear liquid which can be used as an antifreeze and as a paint solvent. On Mir, ethylene glycol flows through the thermal control loops to regulate the temperature throughout the modules. On November 1, 1995, an ethylene glycol leak was discovered on the Mir. Since then, more than 20 leaks have been reported. The uncontained presence of ethylene glycol continues to be a problem on Mir.
Concentrations of ethylene glycol in the condensate recycling system (and presumably in the atmosphere on Mir) are not considered by NASA to cause the crew serious health problems. 14 However, NASA does not know the long-term health impacts of exposure to ethylene glycol in an environment such as the Mir. As a precaution, NASA has advised astronauts not to drink water produced from the condensate recycling system, even though RSA has reported ethylene glycol is currently not present in the recycled water.
The ethylene glycol leaks affect the habitability of the Mir. During leak repairs, the thermal control system is shut down which increases the internal temperature of Mir beyond the nominal range of 82 degrees Fahrenheit. Long periods of temperatures above the nominal range can affect crew productivity.
H. Lack of Knowledge About Mir Systems
Another factor affecting U.S. astronaut operations on Mir has been NASA's lack of knowledge of the Mir, Soyuz, and Progress technical systems, including the key electrical, mechanical and life support systems. Russia restricts NASA's unimpeded access to technical specifications. For example, during a debriefing, NASA managers asked Astronaut Thagard if he could provide a schematic of the Mir power system. He replied,
Bonnie [Astronaut Dunbar] and I both received copies of electrical schematics, but we were asked to not distribute them. It is important to honor this request. Not honoring it jeopardizes future crew members who may not be given data that they need for training.
When asked about what detail he was provided regarding vehicle subsystems, Astronaut Thagard responded,
For some systems; e.g., Life Support System, we got lots of information: specifications, capacities, sizes, and even some hands-on training in a Part Task Trainer. The Russians requested that we not give out some of the information because it is proprietary.
This limited access to technical information inhibits NASA's ability to develop commensurate training for the astronauts assigned to Phase I. Once on board the Mir, they may find themselves in an emergency and ill prepared to help their cosmonaut colleagues. Moreover, this limited access also diminishes the opportunity for the U.S. and other ISS partners' to learn about the more robust features of the various designs and interfaces that may apply to Phases II and III of the ISS program.
I. Russian Pay System
According to American sources familiar with the RSA, the cosmonaut pay and bonus system may affect the risks to American astronauts on board the Mir. The Russian pay system goes beyond flight or hazardous-duty pay as we know it. It includes specific payments for identi- fiably high-risk activities such as Extravehicular Activity (EVA) operation ($1,000 extra), manual docking ($1,000 extra), and additional month-on-board pay. Such a bonus system could incentivize cosmonauts to take risks to earn additional pay. According to a news report, in 1995 when Russian space officials stripped Mir Commander Gennady Strekalov of benefits for refusing to conduct an EVA. Strekalov, citing safety concerns, arbitrated his case upon return to Earth, and won back some of his pay. (See Appendix J.)
III. IMPACTS ON SCIENCE
The objectives established for Phase I science and technology research are: (1) obtain engineering and operational experience conducting research on an orbital space station, (2) characterize the Mir environment relative to microgravity and life sciences research, (3) identify and implement experiments demonstrating technologies and equipment for ISS, (4) and perform EVA.
The Phase I Research Program results were presented to the Phase I Program Management and staff on May 30, 1997. Further results of all scientific research conducted since then were presented at the Shuttle-Mir Research Program Results Symposium held August 5-7, 1997, at the Johnson Space Center. The NASA Phase I Mission Scientist characterized the science program as successful, since the majority of the scheduled science and research had been conducted by May 30, 1997. However, sources involved in the symposium have indicated that some PI's expressed disappointment in those results.
Post-flight science debriefing tapes indicate that all of the long-duration Mir astronauts expressed some concerns and frustrations about the scientific experiments. The astronauts encountered impediments to conducting useful science experiments including: (1) poor instructions from the PI's; (2) poor ground communications and absence of experiment-related telemetry; and (3) onboard interruptions to the experiment caused by moving the experiments about the station, loss of power, and equipment failures.
Other astronaut concerns relate to the poor training and poor instructions they received to conduct the experiments (See Lessons Learned, Appendix I). For instance, the astronauts would receive a book of the science projects they were to conduct that, according to the astronauts, often did not contain all documented procedures for each scientific project. Sometimes instructions were missing or non-existent. During their stay on board Mir, the astronaut would request scientific instructions from ground support. At times, ground support took several days to reply. By then, the astronauts may have proceeded with the experiment and improvised an action different from the PI's final instructions. Some of their equipment did not work properly. These are not only impediments to scientific research, but according to some witnesses may make the results questionable.
The Progress collision and the resulting shutdown of the Spektr module severely curtailed the remainder of scientific research for Phase I. The U.S. science equipment stored in Spektr was lost along with the power needed to conduct those experiments. The impact on planned NASA-6 experiments is unclear, and depends upon the success of the recent IVA repowering of the Spektr. If power to conduct scientific experiments is unavailable during NASA-6, the astronaut's participation may be limited to station maintenance and repairs and very simple science activities.
IV. PHASE I ALTERNATIVES
NASA has several alternatives regarding participation in Phase I activity:
- Maintain the status quo. NASA can continue the current Phase I activity by full participation in Mir crew exchanges, related Shuttle missions, maintenance and emergency repairs, and planned scientific and research activity. If the situation on Mir degrades further, emergency evacuation on the Soyuz remains an option. If immediate evacuation is not warranted but the conditions degrade to an unacceptable level, NASA can remove the astronaut during the next available Soyuz exchange or Shuttle rendezvous.
- Remove American astronauts from Mir, but provide support to the Russian Space Station. Under this scenario, American assistance to and activities with the Mir crews would be limited to the duration of the Shuttle rendezvous missions. If conditions (e.g., power) improve sufficiently, then NASA could try to arrange for Russian cosmonauts to perform science and research activities previously planned for our astronauts.
- Monitor the Russian's ability to improve conditions on the Mir and, if safety conditions improve, return an American astronaut(s) to continue participating in Mir activities.
- Terminate American involvement in Phase I activity, and proceed to Phase II.
The monetary impact of any of these solutions appears minimal. The largest block of Phase I- related funding has already been expended (80%), and only the Fiscal Year 1998 costs remain to be incurred. There also may be some costs associated with terminating the contract.
CONCLUSION
When the Shuttle/Mir program began, the basic safety of the Mir was accepted based upon a known history of apparent safe operations. It appears in recent months that the risk level associated with Mir operations has increased. NASA must conduct credible risk assessments to fully account for the safety standards it now applies to Phase I programs. Those assessments must be based upon understanding the risks involved weighed against the expected benefits of continued operations. In this letter, I have outlined some of the significant risks faced by astronauts aboard the Mir.
We are sending a copy of this letter to the NASA Administrator. If you have any questions or wish to discuss matters in this report in more detail, please contact me.
Sincerely,
Roberta L. Gross
Inspector General
