Date: March 26, 2008 **********DISCLAIMER****************************************DISCLAIMER********* This file contains an ASCII representation of an OIG report. No attempt has been made to display graphic images or illustrations. Some tables may be included, but may not resemble those in the printed version. A printed copy of this report may be obtained by referring to the PDF file or by calling the Office of Inspector General, Division of Operations Support, at (703) 487-5443. ******************************************************************************* AUDIT REPORT Memorandum To: Secretary Kempthorne From: Earl E. Devaney//signed// Inspector General Subject: Final Audit Report, Health and Safety Concerns at Department of the Interior’s Facilities (No. C-IN-MOA-0011-2006) This final report presents the results of our audit to determine whether the Department and bureaus have effectively addressed health and safety issues related to facilities. We found that although much progress has been made, serious weaknesses remain in the health and safety program which result in inadequate protection of employees and the public. Specifically: Deficiencies exist in the organization, coordination, staffing, and recordkeeping of the health and safety program. Many facilities on Department lands currently contain health and safety hazards. Although over three quarters of Departmental and bureau employees that responded to our survey believe they work in a safe and healthy environment, the remaining employees expressed concerns that serious deficiencies currently exist in their workplace. In addition, we issued three Flash Reports during our audit to address the most serious health and safety hazards. We were pleased that the Secretary acted quickly to direct appropriate officials to address the problems. We also found that the Bureau of Land Management’s (BLM) “Compliance Assessment – Safety, Health, and the Environment” (CASHE) program should be looked at as a possible best practice for the Department. For critical health and safety deficiencies that are smaller in project size and/or cost or pose an imminent danger, BLM has been able to mitigate these deficiencies through annual CASHE corrective action funding. In the response to the draft report, the Department concurred with six of the seven recommendations and partially concurred with our recommendation that it develop and implement a Department-wide health and safety program, stating that such a program is already in place. After considering the response, we revised the recommendation to more clearly state our original intention that the Department strengthen the existing program. The response also included an action plan developed by the Department and bureaus to enhance workplace safety. We are pleased that the action plan provides constructive measures that, when implemented, should result in an improved health and safety program. The legislation, as amended, creating the Office of Inspector General requires that we report to the Congress semiannually on all audit reports issued, actions taken to implement our recommendations, and recommendations that have not been implemented. we appreciate the cooperation provided by the Department and bureaus during our audit. A response to this report is not required. If you have comments or questions regarding this report, please call me at (202) 208-5745. Attachment EXECUTIVE SUMMAARY What We Found The Department of the Interior (Department or DOI) and its bureaus made progress in identifying, prioritizing, and mitigating health and safety hazards at the Department’s facilities. However, they do not know if all health and safety issues have been identified because they have not completed all condition assessments and safety inspections of facilities. They have worked to establish and assign the highest priority to health and safety issues, but mitigation of these issues is still not effective. We found health and safety hazards that place employees and the public at risk. Weaknesses in the health and safety program hamper the Department’s ability to identify, prioritize, and mitigate safety hazards. Finally, there is a lack of coordination between the safety and facility maintenance programs. Examples of unmitigated health and safety issues that we found include: Severe deterioration exists at Bureau of Indian Education’s (BIE) elementary and secondary schools. BIE identified that 69 (38 percent) of its 184 schools and dormitories are in poor condition. This deterioration ranges from minor deficiencies such as leaking roofs to major deficiencies like structural weaknesses, outdated electrical systems, and inadequate fire detection and suppression systems. The deteriorating conditions at the Chinle Boarding School in Arizona create the potential for a catastrophic fire or explosion. The National Park Service (NPS) has allowed crucial maintenance to lapse for years at many of its parks. For at least 20 years, NPS has not performed critical maintenance on its aging Wawona Tunnel located in Yosemite National Park. We concluded that the hazardous conditions in the Tunnel endanger lives. At the Jackson National Fish Hatchery in Wyoming, Fish and Wildlife Service and U.S. Geological Survey employees worked for almost seven years in two buildings that were condemned and closed to the public in September 2000. What is Needed The Department and its bureaus must improve and expand their health and safety programs. Improvements should include: could be strengthened. After considering the response, we revised the recommendation to more clearly state our original intention that the Department strengthen the existing program. The Department also established a Special Task Force to oversee the implementation of our recommendations and has developed a Department-wide and cross-cutting plan of action as a result of the Special Task Force and the DASHO Council. TABLE OF CONTENTS Introduction 1 Audit Objective 1 Background 1 Results of Audit 3 Improvements Needed in the Health and Safety Program 4 Health and Safety Issues Related to Department Facilities 9 Employee Perceptions on Health and Safety 16 Recommendations 28 Appendixes A. Objective, Scope, Methodology, and Internal Controls 32 B. Related Reports 34 Sites Visited and Contacted 37 D. Elements of a Well-Designed Health & Safety Program 39 Improvements Needed in Department and Bureau Maintenance Programs 40 Bureau Survey Results 43 List of Figures 51 Abbreviations 52 Department’s Response to the Draft Report 53 Status of Audit Recommendations 68 AUDIT OBJECTIVE The objective of our audit was to determine whether the Department of the Interior (Department or DOI) and its bureaus have effectively identified, prioritized, and mitigated health and safety issues related to its constructed infrastructure that could adversely affect employees and the public. BACKGROUND The Department faces the difficult challenge of maintaining an infrastructure valued at over $65 billion and spread over 500 million acres. The ability to adequately maintain this infrastructure is hampered by limited resources and the aging of the facilities. This infrastructure includes approximately 40,000 buildings; 4,200 bridges and tunnels; 126,000 miles of highways and roads; and 2,500 dams as well as nearly every type of asset found in a local community. The Department employs over 70,000 people and receives about 461 million visits annually. Executive Order 12196 entitled “Occupational Safety and Health Programs for Federal Employees,” effective July 1, 1980, states that “the head of each agency shall furnish to employees places and conditions of employment that are free from recognized hazards that are causing or are likely to cause death or serious physical harm.” The Department’s health and safety program is run by its Office of Occupational Health and Safety. The Department is required by the Code of Federal Regulations (29 C.F.R. § 1960.6) to select a Designated Agency Safety and Health Official (DASHO) who has the primary responsibility for managing the health and safety program. A DASHO Council has been established to provide executive level bureau and office involvement in the formulation of policy and the management of the health and safety program. The Council determines the collective actions needed to achieve the Department’s Occupational Safety and Health Strategic Plan. The Department has more than 175 full-time safety professionals who conduct the health and safety program. Additionally, approximately 1,200 Department employees serve as collateral duty safety officers. Appendix A contains information on the audit objective, scope, methodology, and internal controls. Appendix B lists prior reviews that were related to our audit. Appendix C contains the sites that were visited or contacted. RESULTS OF AUDIT The Department has made progress in identifying, prioritizing, and mitigating health and safety hazards. However, the Department and its bureaus do not know if they have identified all health and safety issues because they have not completed all required condition assessments and facility inspections. The Department and its bureaus have worked to establish and assign the highest priority to health and safety issues, but mitigation of these issues is still not effective. We found health and safety hazards that place employees and the public at risk. We conducted a health and safety survey of the Department’s approximately 71,000 employees and received 9,133 responses. Significant results from the survey include: 77 percent of respondents stated they work in a safe and healthy environment. 80 percent stated the public is safe when visiting their workplace. 56 percent indicated that serious health and safety deficiencies did not exist at their workplace. 66 percent felt that health and safety is a priority of senior level management. Although the survey results indicate that more employees than not are satisfied with the health and safety programs at their workplaces, many significant concerns were still raised. These concerns are explained later in this report. Secretary Kempthorne has affirmed his commitment to health and safety. In a speech delivered on May 22, 2007, at the Main Interior Building, the Secretary stated “I want to emphasize that there is nothing more important to me personally and to the Department’s mission than ensuring that your workplace is healthy and safe and that employees, volunteers and visitors to our parks, refuges, and other lands are protected from hazards, accidents and other dangers.” The Secretary added that health and safety should be “Job 1” at the Department. We issued three Flash Reports during our audit to address the most serious health and safety hazards. After receiving each Flash Report, the Secretary acted quickly to direct appropriate officials to address the problems. A Flash Report describes a situation or condition that is so serious that management must take immediate corrective action. Improvements Needed in the Health and Safety Program The Department’s employee accident rate is one of the highest in the federal government. In FY2006, 4,409 workers’ compensation claims were filed, representing a claim rate of 6.27 out of every 100 employees, exceeding the federal average by 41 percent. That year, the Department paid $58 million in claims and lost 15,000 days of employee work, which equates to 58 work years. The cost of accidents is much greater than workers compensation payments alone. Using a cost estimation methodology devised by the National Safety Council, we estimate that for the five years ending in FY2006, injuries, illnesses, and deaths cost the Department over $480 million. We found that improvements are needed in the health and safety program. For example, the Department does not have: An organizational structure that facilitates an effective health and safety program. Effective coordination between the health and safety and asset management programs. Adequate numbers of trained safety staff. An effective facility safety inspection program. An adequate incident tracking system. The Department has not placed safety officials at the organizational level necessary to ensure they have the visibility and authority to effectively promote safety. The Code of Federal Regulations (29 C.F.R. § 1960.6) states that each agency head will select a Designated Agency Safety and Health Official (DASHO) to operate the agency’s occupational safety and health program. This regulation further requires the DASHO to be the rank of an Assistant Secretary, or equivalent rank. Currently, the Department’s DASHO is the Deputy Chief Human Capital Officer, which is a position two levels below the Assistant Secretary level. We found that other Federal agencies and private sector companies have a chief safety officer at a higher organizational level. For example, the Chief Safety Officers at the Department of Energy, the National Aeronautics and Space Administration, the U.S. Air Force, and Walt Disney Parks and Resorts report to the highest levels of management. By specifically identifying a Chief Safety Officer, these organizations create visibility for their safety programs. Coordination Between Health and Safety and Asset Management Programs The Department has a DASHO Council and an Asset Management Team (AMT); however, their efforts are not coordinated. The DASHO Council was established to provide executive level bureau and office involvement in the formulation of policy and the management of the health and safety program. The Council determines the collective actions needed to achieve the Department’s Occupational Safety and Health Strategic Plan. The AMT is a standing committee of senior asset management officers from each bureau. Its role is to preside over major real property investment decisions and initiatives. The health and safety and facilities programs are interrelated and it is important that they coordinate their efforts. Staffing and Training personnel to help protect its employees and the public and to evaluate thousands of facilities for safety hazards at its approximately 2,400 locations. According to the Department’s FY2006 annual report to the Occupational Safety and Health Administration (OSHA), there are about 1,375 safety personnel; however, only about 175 are full-time positions. The remaining 1,200 are assigned safety only as a collateral duty. We were told that in many cases employees are unwillingly assigned the safety position as a collateral duty. Bureau safety officers also told us that most collateral duty safety personnel do not receive the necessary training to effectively perform their duties. The Department, however, has made progress in identifying the necessary training to be provided to full-time and collateral duty safety officers. In 2006, the Department defined core competencies for these positions and the specific training to be taken. A 2005 staffing study performed by the Department’s Office of Occupational Health and Safety stated that the private sector has traditionally used a 1 to 500 ratio of safety professionals to employees in establishing appropriate safety staffing levels. The report recommended that a 1 to 250 ratio would be realistic for NPS. Using this ratio, the NPS safety staffing level should have been 87 positions in the field units for the 21,869 employees. At the time of the study there were only 28 full time positions. As such, it is likely that many locations are not effectively monitored by adequately trained safety personnel. Bureau Safety Officers reported that they typically do not have line authority over safety personnel stationed in the regions and in the field. One bureau official reported that oftentimes safety positions are the first to be eliminated during budget cuts. Without line authority the official could not ensure that these positions were filled by trained personnel. Well-trained safety officers reduce employee accidents and make a difference. With approximately 71,000 employees, 200,000 volunteers, and over 460 million annual public visits, safety should be on everyone’s mind. Proactive Facility Safety Inspections Some bureaus did not have an effective facility safety inspection program. Specifically, we found that bureaus did not always: conduct the required annual facility safety inspections, use qualified safety inspectors, and ensure that identified deficiencies were corrected. For example, BIA did not complete its health and safety inspections At the lower levels of the bureaus, we also found that safety inspections and condition assessments (both help identify health and safety deficiencies) at individual facilities were not always coordinated. Until the Department and bureaus have coordinated and completed all condition assessments and facility inspections, they cannot know if all health and safety issues have been identified. The Department does not have a sufficient quantity of trained safety for FY2005 and FY2006. For FY2005, 56 percent of BIA’s locations were inspected; and for FY2006, 51.4 percent of BIA’s locations were inspected. Also, a safety manager can enter one inspection report for one building in a compound and the safety manager will get credit for all of the buildings in the compound. At Grand Canyon National Park, facilities are not routinely inspected by the safety officer. We were told by the Park’s safety officer that his focus has been on employee behaviors. We acknowledge that evaluating and directing employee behaviors to prevent accidents is appropriate, but we also believe that the scope of work for safety officials should be extended to inspecting facilities for health and safety hazards. A well-defined and proactive health and safety inspection program is required by 29 C.F.R § 1960.25. The regulations require that all facilities be inspected at least annually, including unannounced inspections; that more frequent inspections shall be conducted in all workplaces where there is an increased risk of accident, injury, or illness due to the nature of the work performed; and that inspectors shall be qualified to recognize and evaluate hazards and to suggest abatement procedures. The Department’s high accident rates support a much more robust facility inspection program. When health and safety issues are identified, they are usually given the highest priority. However, as shown in the examples in the next section, not all health and safety issues have been categorized at the highest priority. BLM’s “Compliance Assessment - Safety, Health, and the Environment” (CASHE) program should be looked at as a possible best practice for the Department. For critical health and safety deficiencies that are smaller in project size and/or cost or pose an imminent danger, BLM has been able to mitigate these deficiencies through annual CASHE corrective action funding. This unique pool of money has enabled BLM to quickly fix various health and safety problems before they escalate. For BLM's critical health and safety deficiency projects that cannot be easily fixed due to cost or size of project, BLM proposes these projects be included in the 5-year Deferred Maintenance and Capital Improvements plan. Incident Tracking System The Safety Management Information System (SMIS) is the Department’s mandatory mechanism for accident reporting and record keeping. We found that data in SMIS was incomplete and cannot be used as an effective tool to help the Department manage the health and safety program. For example: Data on causes of accidents was incomplete. We reviewed accident records for FY2002 through FY2006 and found that 10,934 of the 38,813 records (28 percent) were either missing data in the field that describes the cause of the accident or were coded as “unclassified.” As such, the cause for many of the reportable accidents cannot be tracked and evaluated. When a user inputs the details of an employee accident in the system, the user is offered more than 100 codes from which to identify the accident’s cause. Some of these codes are very similar. To illustrate, there were 28 codes alone just for falling down. However, the Office of Occupational Health and Safety (OHS) is in the process of making changes to the system that will simplify the coding systems. One person performs the programming and system maintenance for SMIS; these duties should be segregated. Lack of segregation of duties increases the risk of unauthorized activities going undetected. Even though OHS management stated that they will accept this risk, we believe the high sensitivity of the data necessitates that adequate security measures be employed. In 2006, OHS moved SMIS to the National Business Center (NBC) which transferred responsibility for security and network operations from OHS to NBC. System security testing should be performed by an independent party. However, the same contractor hired by NBC to complete the system security testing also developed the system security plan and other security documentation. As a result, there are no assurances that adequate security controls are in place. An adequate incident tracking system is vital for supporting a successful health and safety program. Such a system would allow safety managers to evaluate the numbers and causes of accidents to aid in developing corrective actions to prevent similar incidents in the future. Safety should be considered an investment, not just an expense. Studies indicate that $3 to $6 may be saved for every dollar spent on improving workplace safety. These savings relate to avoiding payments to injured workers and medical care providers as well as indirect costs for training replacement workers, repairing damaged property, investigating accidents, and implementing corrective action. In addition, an investment in health and safety may improve employee productivity and morale, and decrease absenteeism. Appendix D provides elements of a well-designed health and safety program. Health and Safety Issues Related to Department Facilities Bureau of Indian Education We believe the Department must take immediate steps to prevent existing hazards from escalating into deadly ones. The following examples illustrate some of the issues we found. We found deterioration at all 13 Bureau of Indian Education’s (BIE) elementary and secondary schools we visited. Deterioration ranged from minor deficiencies like leaking roofs to major deficiencies like structural weaknesses, outdated electrical systems, and inadequate fire detection and suppression systems. In fact, BIE identified that 69 (or 38 percent) of its 184 elementary and secondary schools and dormitories were in poor condition. Below are three examples of the conditions we found. Chinle Boarding School Serious health and safety deficiencies at Chinle Boarding School in Many Farms, Arizona, endangered the lives of the school’s 90 staff members and approximately 385 students. Severe structural cracks and unstable foundations exerted pressure on natural gas lines, electrical wires, and boiler room components. Escaping natural gas or electrical discharges from damaged pipelines or wiring could result in explosions and loss of life. Leaks in the library roof caused two electrical fires; toxic air from the most recent fire forced closure of the library for a month. In addition, the cafeteria had been condemned since July 2006, and the fire alarm system did not work. Shonto Preparatory School The Shonto Preparatory School is a grant school in Shonto, Arizona with approximately 550 students. The school had significant electrical deficiencies that increased the risk of fire and endangered the lives of the students. We found duct tape placed over a circuit breaker to prevent it from tripping, electrical extension cords routed through brick walls and dangling from ceilings, and a fire alarm system that did not work properly. The school’s ongoing rodent problem was a concern for hantavirus, a deadly disease that can be contracted from rodent feces. We also learned of an employee and her husband who became ill with carbon monoxide poisoning caused by a wall furnace within their employee quarters. The Bureau of Indian Affairs (BIA) owns the quarters and the incident could result in a tort claim. Keams Canyon School Keams Canyon School, built in 1928, is a BIE-operated school in Keams Canyon, Arizona. The most serious problem at the school was abandoned buildings, which had not been sufficiently boarded up and could be accessed by children. The buildings had deficiencies that included collapsed floors, flooding, mold, broken glass, and stored toxic chemicals. Additionally, the boiler, which was still in operation, leaked large amounts of water and had not been inspected since 2002, at which time it failed inspection. BIA acknowledged that boilers across the bureau were a health and safety problem after they experienced a small but potentially lethal explosion in the firebox of a boiler in the agency headquarters building on the Pine Ridge Reservation. The bureau reported that this explosion initiated a nationwide review of all boilers, and resulted in substantial amount of work being done on boilers across Indian country. According to a BIA official, the bureau spent $10 million in the early 1990s establishing a boiler inspection program that was discontinued in 1995 due to lack of funding. In May 2007, we issued a Flash Report, Bureau of Indian Affairs and Bureau of Indian Education: Schools in Need of Immediate Action (Report No. C-IN-BIA-0008-2007), to address health and safety issues at BIE schools. We recommended BIA and BIE stabilize or vacate buildings that were in imminent danger of collapse; demolish or prevent access to condemned buildings; and develop and implement inspection and abatement plans to identify and mitigate all health and safety hazards. In his response, the Assistant Secretary for Indian Affairs concurred with our findings and agreed there are significant issues at the schools. Although they did not feel these issues were imminently life threatening, they agreed to implement our recommendations. We contacted ten Park units and found that NPS has allowed crucial maintenance to lapse for years. Below are four examples highlighting serious health and safety issues. Yosemite National Park—Wawona Tunnel The 74-year old, nearly mile-long Wawona Tunnel in Yosemite National Park had lacked adequate maintenance for 20 years. As a result, key safety system components had failed, placing Tunnel users’ lives in danger. The exhaust fans operated below one-third capacity, there were no fire escape exits and carbon monoxide sensors, and no emergency response plan. The Tunnel is located on one of the Park’s major routes and the resulting volume of traffic could expose users to high levels of carbon monoxide. An accident in the Tunnel resulting in a fire could be disastrous. In June 2007, we issued a Flash Report, National Park Service: Hazardous Condition of Yosemite’s Wawona Tunnel Endangers Lives (Report No. C-IN-NPS-0007-2007). We recommended that NPS immediately implement safeguards to protect Tunnel users, an emergency response plan, and a detailed action plan to bring the Tunnel into full compliance with current safety standards and regulations. In her response, the NPS Director concurred with our findings and agreed there are significant concerns in the Tunnel. NPS has identified short-term and long-term actions to implement our recommendations. Grand Teton National Park The Headquarters Administration Office building at Grand Teton National Park in Wyoming did not meet earthquake seismic codes despite the Park’s location near an earthquake fault. The Headquarters Administration Office building included the park’s headquarters and Visitor Center. In the 1990's, excessive snow collapsed a portion of the original Visitor Center’s roof. The park fixed that section of the roof, but did not replace or strengthen the entire roof. In August 2007, NPS opened a new Visitor Center across the road from the original building to make it safer for the public and employees. According to a 2005 report prepared by the Center for Building Performance and Diagnostics at Carnegie Mellon University, employees located in the adjacent Moose Maintenance Facility were working in poor indoor air quality caused by vehicle exhaust coming from a garage where snow plows, dump trucks, and ambulances were kept. The facility was also overcrowded. The maintenance facility houses the Dispatch Center, the Architectural/Engineering Division, Building Operations division, workshops, and extensive areas of garage space. The report made recommendations on how to improve the working conditions in the buildings. Park officials reported that an attempt 10 years ago to add approximately 18,000 square feet of office space to the second floor stalled because of a lack of available project funds. In June 2007, NPS approved a project that would include rehabilitating the Moose Maintenance Facility over the next 6 years. Dinosaur National Monument Dinosaur National Monument was created in 1915 to protect the world’s largest Jurassic Period dinosaur fossil collection. NPS constructed the Quarry Visitor Center in 1958 to shelter the fossil collection, unique because the exposed fossils remain embedded in the mountainside. The Visitor Center was literally falling apart due to expanding and contracting soils that affect the building’s structural integrity. In 1992, NPS concluded that the continued maintenance was merely a stop-gap measure and that the entire structure should be rehabilitated or reconstructed. Fifteen years later, the project for the new visitor center remains in the planning stage. The current Visitor Center closed its doors in July 2006 due to safety hazards. While NPS protected lives by closing the Visitor Center and restricting access to employees, the rapid deterioration of the building continued to put the irreplaceable fossils at risk. The day-to-day maintenance that is essential to keep the building standing has not been performed. As a result, the fossils were being degraded by exposure to weather and vermin droppings. Additionally, one of the exhibit hall walls was in danger of collapsing. The closure of the Visitor Center had other effects as well. Approximately 350,000 annual visitors, including research scientists, were denied access to the quarry; the primary reason the Monument was created. Water Systems Providing safe drinking water and properly disposing of wastewater at Yosemite and Yellowstone National Parks present a growing risk to the health of employees and the public. Combined, these parks operate 47 drinking water and 42 wastewater systems. An official at Yosemite stated that the park struggles to keep its aging systems running and repairs are usually not made until the facilities break or fail. In addition, two of Yosemite’s water systems did not comply with Federal health regulations and many of Yellowstone’s systems were in various states of deterioration. Jackson National Fish Hatchery At the Jackson National Fish Hatchery near Jackson, Wyoming, Fish and Wildlife Service (FWS) and U.S. Geological Survey employees worked in buildings that were condemned and closed to the public in September 2000. A seismic evaluation revealed structural deficiencies so dangerous as to require the buildings to be either permanently evacuated or demolished and reconstructed. Although employees were told to move their offices to a trailer in September 2006, they continued to work in the condemned fish production buildings to restock endangered trout. In May 2007, we issued a Flash Report, Fish and Wildlife Service: Jackson National Fish Hatchery in Need of Immediate Action (C-IN-FWS-0009-2007), to alert FWS about this condition. We recommended that they prohibit access to the buildings and ensure that resources are made available for design and construction of replacement buildings. In its response, FWS concurred with our recommendations and stated it was addressing the situation. Most of the approximately 2,300 dams located on the Department’s lands are earthen structures which are used for irrigation, water supply, or flood control. The Department tracked 457 of these dams on its Technical Priority Rating Report. The dams on this list were rated on technical information, observation by trained personnel, and the potential for loss of human life. Technical information included testing for seepage (water penetrating the dam) and hydrology (water overtopping the dam). Fifty-nine of these dams received the most critical ratings possible for seepage and/or hydrology. Should any of these dams fail, human life would be at risk. We visited 8 of the worst ranked dams. The dams were operated by BIA and FWS, and below are two examples. Weber Dam Weber Dam, located on the Walker River Paiute Tribe Indian Reservation in Nevada, was ranked as the worst dam on the Report. This earthen dam was built in about 1934 on an earthquake fault. In 1983, the Bureau of Reclamation (BOR) issued a report that rated the safety classification of the dam as “poor” because of an inadequately sized spillway. A flood could cause the dam to overtop, potentially resulting in loss of life in the downstream floodplain, which includes the town of Schurz. Another identified issue was the potential for failure of the foundation during an earthquake. In this case, construction had begun in 2007 to build a replacement dam. Santa Ana Dam Santa Ana Dam, located on Santa Ana Pueblo lands in New Mexico was the third worst dam on the Report. The earthen dam was built in 1960 for flood control. During heavy rains the dam protects the approximately 110 residents that live nearby. Due to seepage and hydrology problems, the dam did not work as intended. As a result of a dam failure in the 1990’s, BIA cut a partial “breach” into the dam in 1997 to allow water to flow through. This action was intended to divert water away from populated areas. However, this was intended as a stop-gap measure until funds were available to permanently address the dam’s safety deficiencies. The Department is aware of the dangers associated with many of its dams and has taken some actions to mitigate them. For example, where necessary they breached dams or lowered reservoir water levels to reduce the stresses on dam structures. However, in many cases the Department did not act on deficiencies until they reached a crisis point. Program managers cited lack of funds or resources to fix the problems. They also indicated that in some cases, the dams were no longer needed and should be torn down, but they did not have the authority to do so. We noted that BIA reported it is in the process of installing early warning systems and preparing emergency action plans at many of its dams. In addition, the Department reported that BOR has emergency action plans already in place for all its high or significant hazard dams. A contributing factor to the problems we noted was the lack of adequate maintenance on Department facilities. We addressed this issue in our 2001 report, “Maintaining the Department of the Interior’s Facilities: A Framework for Action (Report No. 2002-I-0008).” Appendix E provides updated information on the Department’s maintenance program. Employee Perceptions on Health and Safety From March to May 2007, we conducted a Department-wide employee health and safety survey to better understand employees’ perceptions of health and safety as part of our audit of the Department’s health and safety program. We distributed the survey to approximately 71,000 employees and received 9,133 responses, a return rate of 13 percent. The first four questions of our employee survey related to Department demographics, such as the bureau or office of the respondent; a primary workplace description (such as an office building or an outdoor environment); a general job classification; and whether the individual was or was not a supervisor. We asked these questions so that we could better quantify the results and provide feedback by bureau. Contact information such as a name, address, phone number, and email address was strictly voluntary. We received the highest percentage of responses from the Bureau of Reclamation (BOR), BIA, which includes Bureau of Indian Education, and U.S. Fish and Wildlife Service (FWS). We received the lowest percentage of responses from U.S. Geological Survey (USGS) (Figure 1). Figure 1. Survey Response Rate by Bureau. (see page 16, PDF version) The greatest percentage of respondents (20 percent) stated they worked in Management, Administrative, Clerical, and Office Services roles. Teachers, administrative, maintenance, and other employees who work in Indian schools comprised 13 percent of the respondents. The category “Other” made up another 13 percent of the respondents. “Other” included such occupations as museum curators, land surveyors, librarians, and cultural resource specialists (Figure 2). In addition, three-fourths of the survey respondents were in non-supervisory roles. Figure 2. Respondents' Area of Occupation. Sixty-seven percent of respondents reported their primary workplace is an office building. The next highest percentages were those that worked in schools and in the outdoors (Figure 3). Figure 3. Workplace Description. Overall, 77 percent of respondents stated that they work in a safe and healthy environment and 80 percent stated that the public is safe when visiting their workplace. However, 22 percent stated that serious health and safety deficiencies currently exist in their workplace. Respondents provided numerous examples of serious, unsafe conditions. Below we summarize key results from the survey. Appendix F contains the complete survey results by bureau for each survey question. Uncorrected Health and Safety Issues Overall, one out of five respondents (22 percent) stated that serious health and safety deficiencies currently exist in their workplace. Only 56 percent of respondents believed that serious health and safety issues did not exist. Results varied by bureau (Figure 4). BIA, Departmental Offices (DO)1 and National Park Service (NPS) had the highest percentages of respondents that reported the existence of serious deficiencies. Figure 4. Results of Questions Related to Uncorrected Health and Safety Deficiencies. The following is a summary of the most common areas of concern from the comments we received that identified existing health and safety issues. Air Quality and Exposure to Hazardous Substances Survey respondents commented on poor air quality; heating, ventilation, and air conditioning problems; and exposure to hazardous substances at their workplaces. Reasons given for the poor air quality included dirty air filters, inadequate building ventilation, construction debris, and falling brick dust from deteriorating buildings. Many respondents were concerned about exposure to hazardous substances such as mold, radon, asbestos, and cigar and cigarette smoke. Others were concerned about being continually exposed to rodent and insect infestations. These concerns, if not mitigated, may cause serious illnesses over the long-term. _________________________ 1Departmental Offices includes Office of the Secretary; Office of Policy, Management, and Budget; Office of the Solicitor; Office of the Special Trustee for American Indians; and Office of the Chief Information Officer. The survey excluded employees from the Office of Inspector General. During our audit we found an instance of mold at a BIA school administration building. Following our discovery, the BIA replaced the wallboard that contained the mold. According to the Environmental Protection Agency web site, all molds have the potential to cause health effects and symptoms, including allergic reactions. Additionally, employees also expressed concern about water leaks and flooding damage that had not been mitigated. Their concern included the potential for mold. Maintenance and Janitorial Services Employees expressed concern regarding the lack of general maintenance and janitorial services. Items as simple as changing light bulbs and filling holes were not being addressed. Some of the maintenance related concerns included: Overloaded electrical systems and exposed wiring. Tripping and slipping hazards, including inadequate snow and ice removal and uneven walking surfaces. Slips, trips, and falls contributed to 26 percent of the Department’s workers compensation claims in 2006. Hazardous trees on trails and picnic areas that are not being addressed. Another area of concern was the insufficient or lack of regular day-to-day janitorial services. Employees commented on filthy restrooms and workspaces. Some employees also believe that they have contracted illnesses related to the unsatisfactory, unclean working conditions. Handicap Accessibility The Architectural Barriers Act of 1968 requires that buildings and facilities that are designed, constructed, or altered with Federal funds or leased by a Federal agency, comply with Federal standards for physical accessibility. Employees reported that: Handicap accessible door openers do not work. Elevators do not work or do not exist. Structural Under the structural category we considered such conditions as lack of seismic reinforcement, shifting walls and cracks in walls, and employees working in condemned buildings. Apparently, some Department employees are working in or dealing with structurally challenged buildings. The scope of our employee survey did not include validating the existence of health and safety deficiencies cited by the respondents. However, we did obtain additional information on some concerns as described below. Main Interior Building Twenty-eight percent of respondents from Departmental Offices stated that serious health and safety deficiencies exist in their workplace. We attribute this high percentage mainly to the Main Interior Building Modernization Project. The Modernization Project is a multi-year rehabilitation designed to improve the infrastructure, including heating, ventilation, and air-conditioning systems; plumbing; and electrical systems. The chief purpose of the project is to improve the health and safety conditions for all of the building’s employees and visitors. Approximately 1,700 employees work in the Main Interior Building. The National Institute for Occupational Safety and Health completed a health hazard evaluation of the Modernization Project in August 2006 and made recommendations, including improving the indoor air quality of the building. In January 2007, at the National Business Center’s (NBC) request, BLM conducted a Compliance Assessment - Safety, Health, and the Environment (CASHE) evaluation for the Main Interior Building. This site assessment found numerous safety and environmental related deficiencies. While the Department states that it is addressing the deficiencies and precautionary measures are being taken to keep employees and the public safe, employees continue to express concerns regarding their health that they attribute to working in the building. BIA Standing Rock Agency Approximately 40 employees work in the Standing Rock Agency building in Fort Yates, North Dakota despite a structural investigation identifying several building deficiencies and concerns voiced by BIA safety personnel. An engineering firm visited the building in December 2003 and made several recommendations, two of which dealt with stabilizing the foundation and establishing wall-to-floor ties to further stabilize the building. According to a BIA Deputy Realty Officer, the Bureau responded by attempting to cover the cracks in the walls by filling them with rubberized caulking and by using long bolts to stabilize brick walls. However, all repairs have been cosmetic; the walls continue to crack and the floors shift. In addition, a new cooling system was installed that leaks. Now, employees also have to deal with wet insulation hanging down like a “water balloon,” damp carpet, and light fixtures full of water. NPS Alaska Aviation NPS pilots at Denali and Lake Clark National Parks in Alaska work in conditions that have been reported as unsafe for nearly 10 years by Departmental aviation safety experts. The airplanes are primarily used for search and rescue, wildlife surveys, scientific research, and law enforcement patrol. Denali National Park alone has over six million acres of land to patrol. Due to the lack of aviation hangars, aircraft at these two parks are stored outdoors in the harsh winter climate. This requires NPS pilots to perform hours of extensive preflight inspections in sub-zero weather with wind chills many times reaching minus 70 degrees Fahrenheit; subjecting themselves to the harsh elements while attempting to reduce the dangerous flight risks involved with storing aircraft outside. As a result of these conditions, emergency responses are also hindered, leaving employees and the public at risk. Additionally, there is a risk of sabotage to the airplanes when left unsecured. Park managers stated they have requested funding for several years to mitigate this serious health and safety risk, but their attempts have been unsuccessful. Reporting and Mitigation of Issues About two-thirds of respondents stated that health and safety concerns are addressed in a timely manner and that the more serious health and safety issues are corrected before the less serious ones. In addition, 72 percent of employees believed that their bureau was doing an effective job of reducing job-related accidents at the workplace (Figure 5). Figure 5. Results of Questions Related to Reporting and Mitigation. Some respondents indicated they are reluctant to report a health and safety concern because of fear of reprisal and in some cases, a hostile working environment. Some respondents also felt reluctance because of pressure to maintain a good safety record. For example, although one respondent was encouraged to seek medical treatment the day of an accident, they were discouraged from taking the next day off because it would be considered a “lost time incident.” The comments identified several challenges facing the Department in getting issues mitigated. These challenges included: Shortage of funding and personnel. This includes shortage of maintenance and safety staff. Bureaus have to do more with fewer resources. Respondents stated that decreases in staffing and increased workloads have resulted and could potentially result in more accidents. Also, we found during our audit that some bureaus do not have separate funding for the mitigation of health and safety deficiencies and thus are competing with other programs for funding. Lack of or untimely response from management. Respondents felt that concerns raised to management were ignored; not taken seriously; or if addressed, sometimes took years to correct. Lack of or untimely response from building owners. Although we did not review lease agreements, bureau management should hold building management accountable if maintenance and janitorial services are not being provided. Respondents also stated that health and safety concerns are not always mitigated based on risk or seriousness. Instead concerns are addressed only if there is a “quick fix” or the cost is minimal. Priority of Health and Safety As demonstrated in Figure 6, 80 percent of employees believed that health and safety was a priority of their fellow workers; however, for their supervisors and senior management the percentages dropped to 77 percent and 66 percent, respectively. The Departmental Offices responded with only a 45 percent belief that health and safety was a priority for senior level management. We attribute this low percentage primarily to the concerns related to the Main Interior Building as previously discussed. Figure 6. Figure 6. Results of Questions Related to Health and Safety as a Priority. A Reactive Versus Proactive Culture Throughout our review of the survey comments, concerns about the Department and bureau culture of health and safety were raised. The general theme of numerous comments is that health and safety is “lip service” only, is second to getting the job done and that there is a reactive versus proactive culture in regards to health and safety. Specifically, comments concerned: Employees taking unnecessary risks to get the job done. Lack of safety awareness in the workplace. Specifically, managers are not promoting safety to their employees. The general complacency of managers and fellow employees of the substandard conditions in which they are required to work. Lack of accountability for health and safety and no consequences for not performing a duty safely. Lack of access to information, such as test results for hazardous substances in facilities or safety plans. Safety officers do not have appropriate authority. The belief that the Department is not required to comply with requirements such as Occupational Safety and Health Administration (OSHA) standards. Hazardous Duty We also developed questions specifically related to those employees whose jobs were considered hazardous duty. The intent of these survey questions was to determine if those hazardous duty employees were receiving the appropriate training on their duties, appropriate personal protective equipment (PPE), and training on the use of their equipment. PPE includes a variety of devices and garments designed to protect employees from serious workplace injuries or illnesses resulting from contact with chemical, radiological, physical, electrical, mechanical, or other workplace hazards. Fifteen percent, or 1,385 of the respondents, stated that their job was classified as a hazardous position. More than three-fourths of these employees stated that they are receiving the appropriate training and equipment related to their duties. See Figure 7 for the results by question. Figure 7. Results of Questions Related to High Hazard Jobs. While the results seem positive, we are still concerned about the many employees performing their duties without required and necessary training and equipment. We received numerous comments that related to employees: Purchasing their own equipment, such as safety goggles, or purchasing equipment for others. Having outdated or expired equipment. Receiving and using equipment without appropriate training. Not receiving initial or refresher training on duties. Not receiving adequate medical monitoring. Employees commented that requests for training and equipment are denied because of lack of funding and management support. The Departmental Manual (485 DM 20) requires each bureau and office to establish a written PPE program that includes assessment of hazards, selection of the necessary PPE to protect employees, and requirements for employee use of the equipment. The Manual also requires each bureau and office to ensure employees use the PPE, that the PPE is adequately maintained, and that training is provided. We did not audit the effectiveness of the bureaus’ PPE programs, but the bureaus may want to consider revisiting its program to ensure employees that require PPE are receiving it and the appropriate training. Radio Communications We issued an audit report “Department of the Interior – Radio Communications Program” (Report No. C-IN-MOA-0007-2005) in January 2007 in which we concluded that the Department has an unsafe and unreliable radio communications environment that jeopardizes the health and safety of employees and the public. We received numerous comments from personnel who further substantiated that there is a serious safety issue related to the lack of reliable radio communications. Specifically, radios are outdated, are not working, and coverage is minimal. Also, due to decreases in staffing, many employees are working in remote locations alone without adequate communications. Although the Department is taking action to address our recommendations, this issue should continue to be on the forefront of Departmental priorities. Department’s SafetyNet Website We asked employees if they had accessed the Department’s SafetyNet website to obtain health and safety information to determine if there was an awareness of not only the website but also of the Department’s Office of Occupational Health and Safety (OHS). Only 36 percent of employees had accessed the website. Many respondents stated that they did not even know the website existed. The OHS position responsible for updating the website was vacant for a year and was just recently filled. Therefore, the site has not been kept up-to-date. Once the website is back on track, it can be a valuable resource for all employees. The Department should promote more awareness of its SafetyNet website and ensure that information is updated regularly. We received thousands of comments from the survey. We wanted to bring as many issues to light as possible in this report so that Department and bureau management would be aware of employee concerns. Below is a summary of the areas of concern that did not specifically apply to our survey questions above. Security and Emergency Preparedness In the category of general security and emergency preparedness, we included such issues as facility security, terrorism, fire protection and drills, border security, hurricane and earthquake preparedness, and faculty and student confrontation. Survey respondents are concerned about easy entrance into their workplaces, lack of qualified personnel in security positions and at guard stations, increased violence on Federal lands, and protection in severe weather and from possible terrorism. Employees also indicated that their offices do not have emergency response plans. We also received numerous comments related to the lack of adequate fire alarms, fire suppression, egress, and fire drills. The Virginia Tech shootings occurred during the period that employees were responding to our survey. As such, many concerns were voiced about the potential for violence in BIE schools. We felt that some of the comments warranted attention by the Bureau of Indian Education and these were provided to appropriate officials for further review. The comments not only indicated potential violence by students, but we received comments regarding the overall security of the schools and the potential for outside individuals having easy access to the schools. Some schools are located adjacent to prisons and along the Mexican border and comments indicated that the schools are not secure. General Health and Safety Additional Issues Raised We received many comments related to general health and safety. Some of the more significant comments related to the lack of attention to work-related stress and mental health. Respondents commented that they are working under significant stress for a variety of reasons, such as hostile working environments, performing additional duties because of short-staffing, and the pressure of getting work accomplished on stricter deadlines with less resources. Additionally, employees expressed concern related to: Lack of fitness programs at their bureau. The need for ergonomic evaluations and ergonomically-friendly office equipment. Lack of safe drinking water. Employees stated that drinking water is not available and sometimes they have to buy their own bottled water. If the water fountains are functioning, the water is discolored and has odors. Lack of first-aid equipment. Lack of training in specialized areas, such as driving all-terrain vehicles or working in confined spaces. Lack of general training, such as CPR/first aid and supervisor training, which is required by OSHA. Even though survey comments indicated that there are numerous health and safety concerns in the Department, other employees were supportive of their bureaus’ efforts, especially at the local level, to manage health and safety for employees. For instance, one BOR employee stated that, "I have found Reclamation's safety practices and concerns to be first-class." Employees were appreciative of the efforts and dedication of their safety officers to maintain safe working environments and acknowledged that management support is a key to establishing a successful safety-conscious culture. Employees also provided examples of health and safety efforts at the field office level, such as the active role of safety committees. Conclusion The Department needs to take immediate steps to prevent existing hazards from escalating into more serious ones. We believe that the following recommendations will help the Department prevent the escalation of health and safety deficiencies. Recommendations We recommend the Secretary: Appoint the Assistant Secretary for Policy, Management and Budget as the DASHO to comply with 29 C.F.R. § 1960.6. DOI Response On January 9, 2008, the Secretary appointed James Cason, Associate Deputy Secretary, in his delegated capacity as the Assistant Secretary for Policy, Management and Budget, as the Department’s DASHO. OIG Analysis of DOI Response We consider the recommendation to be resolved and implemented. Establish a full-time position, called Chief of Health and Safety that serves as the DASHO’s advocate for health and safety. This advocate would work with the existing DASHO Council and Asset Management Team to ensure coordination and to ensure that identified issues are raised to the appropriate level for decision making. DOI Response The Department concurred with the recommendation and stated that it is in the process of creating a Chief of Health and Safety to serve as the DASHO’s advocate for health and safety and who will work with the DASHO Council and the Asset Management Team. A review will be completed and recommendations made on ways to improve management focus on safety issues by strengthening the bureau and field health and safety organizational structure. The DASHO Council has been expanded to include the Associate Director of Facility and Property Management, who chairs the Asset Management Team. The Department’s Deputy DASHO has been added to the Asset Management Team and four members of the DASHO Council also currently serve on the Asset Management Team. OIG Analysis of DOI Response We consider the recommendation to be resolved, but not implemented. Strengthen its Department-wide health and safety program that covers employees and the general public. This should be based on the elements of a well-designed health and safety program described in Appendix D and should reduce the reliance on collateral duty assignments by establishing a sufficient number of full-time health and safety personnel. DOI Response The Department partially concurred with the recommendation in the draft audit report which called for the Department to develop and implement a Department-wide health and safety program that covered employees and the public. The response stated that the Department and its bureaus currently have a good health and safety program, but acknowledged that the program can be strengthened by a more focused strategic plan with more measurable goals. The Departmental strategic plan for health and safety will be updated to incorporate the elements of a well-designed health and safety program, including staffing levels. OIG Analysis of DOI Response We recognize that the Department has an established health and safety program in place. The intent of the original recommendation was to improve the program by implementing more proactive measures to protect the health and safety of employees and the public. We are pleased that the Department’s action plan included with its response identified significant measures to be taken in this regard. Nevertheless, for clarity, we revised the report to recommend that the Department “strengthen” the program. We consider the revised recommendation resolved, but not implemented. Develop and implement a Department-wide action plan with milestones to eliminate significant health and safety deficiencies. DOI Response The Department concurred with the recommendation and stated that as part of a Department-wide action plan to enhance occupational health and safety, its action plan includes tasks to develop a Department-wide framework for identifying and categorizing significant deficiencies and developing bureau-specific plans to eliminate the significant deficiencies. Each bureau plan will be based on a common definition of “significant deficiency” and will use a common risk assessment methodology to determine corrective actions necessary within budgetary and operational constraints. OIG Analysis of DOI Response The action plan included with the response identified measures to be taken that should help eliminate significant health and safety deficiencies. The Department’s strategy appears sound and, therefore, we consider the recommendation resolved, but not implemented. Develop a Department-wide funding strategy to ensure that health and safety issues are timely and effectively addressed. DOI Response The Department concurred with the recommendation and stated that it has funding set aside for cross-cutting safety initiatives and the bureaus also have budget processes that prioritize their health and safety needs. The primary responsibility for addressing health and safety issues belongs to the bureaus where the issues are identified. The Department will identify ways to strengthen the process for ensuring that issues are corrected and will reprioritize funding as needed to implement the action plan to address significant health and safety deficiencies. OIG Analysis of DOI Response Although the Department asserted that funding is available and bureau budget processes are in place, we still identified serious deficiencies during our audit. This underscores the difficult challenge confronting the Department. However, the action plan included with the response includes initiatives that should help eliminate significant health and safety deficiencies. Therefore, we consider the recommendation resolved, but not implemented. Develop a plan that ensures all managers, employees, and health and safety staff receive appropriate training concerning health and safety. DOI Response The Department concurred with the recommendation and stated that it will develop an inventory of currently available safety and health training, including delivery methods, mandatory requirements for specific positions, and required frequency for completing mandatory training. The Department will maximize the use of DOI Learn for training delivery. Training requirement for all supervisors and employees will be identified. OIG Analysis of DOI Response The action plan included with the response identified measures that when implemented should help ensure all managers, employees, and health and safety staff receive appropriate training. Therefore, we consider the recommendation resolved, but not implemented. Improve the SMIS system by: simplifying the data entry system, requiring input of both employee and visitor accidents, establishing controls to ensure that incident reporting data is accurate and complete, and enhancing security. DOI Response The Department concurred with the recommendation and stated that while SMIS provides valuable health and safety information to managers, there are areas where its performance can be enhanced. A work group has been formed to review the performance of the existing SMIS within the context and recommendations of the report, remedy issues with the existing SMIS, and review alternative solutions to provide the most effective reporting and tracking program. OIG Analysis of DOI Response The Department’s response and its action plan include measures that should improve the identification and tracking of health and safety incidents. However, we want to emphasize that the system should fully identify and track incidents for both employees and visitors. We consider the recommendation resolved, but not implemented. Appendix A — Objective, Scope, Methodology, and Internal Controls Objective To determine if the Department of the Interior and its bureaus have effectively identified, prioritized, and mitigated health and safety issues related to its constructed infrastructure that could adversely affect employees and the public. Scope The scope of our audit covered fiscal years 2002 to the present and included deferred maintenance and health and safety activities at the Departmental level and all bureaus. Upon completion of our audit survey, our primary focus was limited to NPS, BLM, FWS, BOR, and BIA/BIE. These bureaus manage the majority of the Department’s infrastructure. We excluded activities related to homeland security, wildland fire, border security, law enforcement, and the Aviation Management Directorate (formerly known as the Office of Aircraft Services). Methodology To accomplish the audit objective, we: Conducted the audit in accordance with Government Auditing Standards issued by the Comptroller of the United States. Included tests of records and other audit procedures that were considered necessary. Gained an understanding of the Department’s health and safety programs. Interviewed Departmental and bureau officials at the headquarters, regional, and field office levels. Conducted a formal survey of Departmental and bureau employees to identify their concerns regarding health and safety. Visited selected bureau sites to identify unmitigated health and safety issues. We selected sites based on preliminary assessments that identified a potential for health and safety issues. Identified best practices from other federal agencies and private industry. Analyzed management processes for identifying, prioritizing, and correcting health and safety deficiencies related to the Department’s constructed infrastructure. Determined the effect of unmitigated health and safety deficiencies (e.g. facility closures, park/site closures, deaths, illnesses, and environmental impacts). Estimated the costs of incidents based on OSHA statistics and cost information methodology developed by the National Safety Council. Employee Survey Methodology We invited all of the approximately 71,000 Department employees to participate in the survey. The survey did not include volunteers or contractors. The survey was conducted from March to May 2007. Employees completed the survey primarily through a website developed in-house by the OIG. For those bureaus and offices that did not have Internet access, employees were able to fax or mail their responses. This included BIA, Office of the Solicitor, Office of the Special Trustee for American Indians, and Office of Hearings and Appeals. Internal Controls As part of the audit, we performed an evaluation of the Department and its bureaus’ systems of internal controls related to the identification, prioritization, and mitigation of health and safety deficiencies for constructed infrastructure. This evaluation was conducted at Departmental and bureau offices to the extent we considered necessary to accomplish the audit objective. Although we found that the Department has progressed in identifying, prioritizing, and mitigating health and safety deficiencies, we found unmitigated health and safety deficiencies and weaknesses in the safety program. These deficiencies are discussed in the Results of Audit section of the report. Our recommendations, if implemented, should improve the internal controls in the areas with identified weaknesses. We also reviewed the Department of the Interior’s Performance and Accountability Reports for fiscal years 2005 and 2006, and noted that in 2005 the Department reported material weaknesses related to maintenance of Bureau of Indian Affairs detention facilities and inadequate Department-wide maintenance management capability. In 2006, the Department downgraded the material weakness related to detention centers to bureau specific with a targeted correction date of 2008. In regards to the material weakness related to inadequate maintenance management capability, the Department determined that this weakness has been corrected because the facility management system had been implemented. Appendix B — Related Reports The Office of Inspector General and the Government Accountability Office (GAO) issued the following reports on deferred maintenance and health and safety since FY2000. Program Assessment Rating Tool, Review of Bureau of Indian Affairs Road Maintenance Program (Report No. C-RR-BIA-0010-2006) March 2007 The OIG review found that BIA has made progress in implementing three OMB recommendations for program improvement. We addressed each recommendation in the report and provided suggestions that BIA might take to improve its Program Assessment Rating Tool rating. Testimony: Department of the Interior, Major Management Challenges (Report No. GAO-07-502T) February 2007 GAO reported that while the Department made progress in addressing prior recommendations related to deferred maintenance information, the maintenance backlog continued to grow. The Department has not received adequate funding for the repairs and maintenance of facilities and, as a result, the deterioration of facilities could adversely impact public health and safety, reduce employees’ morale and productivity, and increase the need for costly major repairs to structures and equipment. Department of the Interior, Radio Communications Program (Report No. C-IN-MOA-OOO7-2005) January 2007 The OIG audit found that the Department and its bureaus did not effectively manage the radio communications program. Radio communications in the Department were unsafe and unreliable for three primary reasons: (1) The poorly maintained infrastructure posed physical safety hazards, and did not support reliable communications, (2) The new radio technology adopted by the Department did not effectively meet users' needs, and (3) the Department had a fragmented radio communications program that failed to connect the two critical components - infrastructure and equipment Indian Irrigation Projects – Numerous Issues Need to be Addressed to Improve Project Management and Financial Sustainability (Report No. GAO-06-314) February 2006 GAO reported that BIA estimated the cost for deferred maintenance at its 16 irrigation projects at about $850 million for 2005, although this estimate was being refined. BIA’s management of some irrigation projects had serious shortcomings that undermine effective decision-making about project operations and maintenance. The National Park Service's Recording of Facility Maintenance Expenditures (Report No. C-IN-NPS-0013-2004) January 2005 The OIG audit found that NPS did not accurately report its facility maintenance expenditures. Consequently, it was not possible to determine how much was spent on facility maintenance efforts. We believed the problem was one of inaccurate data collection or recording rather than non-performance. Flash Report: Public Safety Concerns At Floyd Bennett Field, Gateway National Recreation Area (Report No. C-IN-NPS-0001-2005) November 2004 OIG reported that aircraft hangars at Floyd Bennett Field were in dilapidated condition and presented potential safety risks to the visiting public. Dangerous conditions included: unsafe structural conditions including a partially collapsed roof; storage of unsecured machinery, industrial equipment, chemicals, and other unlabeled and unknown substances; and uncovered vertical shafts, approximately four to five feet deep, some of which were filled with water, in the concrete floor of both aircraft hangars. Special Report: Neither Safe nor Secure: An Assessment of Indian Detention Facilities, (Report No. 2004-I-0056) September 2004 The OIG audit found that BIA has failed to provide safe and secure detention facilities throughout Indian Country. The assessment revealed a long history of neglect and apathy on the part of BIA officials, which resulted in serious safety, security, and maintenance deficiencies at the majority of the facilities. The maintenance backlog at these facilities was significant, funding was haphazardly managed by BIA, training of personnel was inconsistent and unpredictable, and basic jail administration procedures and standards were neither followed nor met at most facilities. Testimony: Recreation Fees- Comments on the Federal Lands Recreation Enhancement Act, H.R. 3283 (Report No. GAO-04-745T) May 2004 GAO reported that H.R. 3283 would provide agencies with a permanent source of funds to better address their maintenance backlog and by making the program permanent, the act would provide agencies an incentive to develop a system to track their deferred maintenance backlogs. Bureau of Indian Affairs – School Construction Program — Improvements Needed to Ensure Safety And Program Performance (Report No. W-FL-BIA-0047-2002) February 2004 The OIG audit found that BIA did not ensure that school buildings were not occupied until identified safety deficiencies were corrected and BIA had inspected and certified the facilities for occupancy. Bureau of Indian Affairs Schools — New Facilities Management Information System Promising, but Improved Data Accuracy Needed (Report No. GAO-03-692) July 2003 GAO reported that BIA’s Facility Management Information System is designed to address the previous data systems’ shortcomings and appears to have the capability to meet BIA’s needs if the data entered is accurate and timely. GAO determined that measures for controlling the quality of new data for individual schools were not working well and nearly half of the proposed entries coming through the system were inaccurate and incomplete. However, based on a review of data for 14 BIA schools, GAO concluded that none of the unentered data were for urgent or safety deficiencies that needed immediate attention. Bureau of Land Management— Improvements Needed In Developing and Reporting On GPRA Goals and Measures: Reducing Threats to Public Health, Safety, and Property” (Report No. 2002-I-0047) September 2002 The OIG report identified that BLM needed to improve its current performance goals and measures for its program activity to reduce threats to public health, safety, and property. Additionally, the OIG recommended that BLM consider adding at least two comprehensive safety and property goals and/or measures related to visitor and employee safety and deferred maintenance. National Park Service: Status of Efforts to Develop Better Deferred Maintenance Data (Report No. GAO-02-568R) April 2002 GAO reported that NPS had made progress in developing a new asset management process that should, when fully and properly implemented, provide the agency with more accurate and reliable estimates of the amount of deferred maintenance of its assets. However, while GAO considered the new process promising, GAO concluded that its success could not be determined until staff in each of the park units was trained and the new asset management process was fully and properly implemented. Maintaining the Department of the Interior’s Facilities, A Framework for Action (Report No. 2002-I-0008) December 2001 The OIG report identified two levels of action that the Department of the Interior needed to take to implement an effective facilities maintenance program. The most urgent short-term action was for the Department to act immediately to reduce the deferred maintenance backlog. The second action was to develop a proactive maintenance program by: appointing a Departmental Chief Maintenance Officer, exploring the establishment of a single maintenance budget, conducting condition assessments, establishing performance measures, and implementing an integrated facilities management system. Park Service – Agency is Not Meeting its Structural Fire Safety Responsibilities (Report No. GAO/RCED-00-154) May 2000 GAO reported that structural fire safety efforts in national parks were not effective. These deficiencies included such fundamental things as inadequate fire training for employees, inadequate or nonexistent fire inspections, and — for many buildings — inadequate or nonexistent fire detection or suppression systems. These deficiencies occurred principally because local park managers were not required to meet minimum structural fire safety standards and because structural fire activities had been a low priority within the agency for many years. Deferred Maintenance, U.S. Fish and Wildlife Service (Report No. 00-I-226) March 2000 The OIG report revealed that FWS did not allocate all funding for deferred maintenance projects on the basis of project priorities and did not ensure that available funding for deferred maintenance projects were used for its designated purposes. The OIG also found deferred maintenance data to be unreliable and deferred maintenance costs undeterminable as all assets had not received condition assessments. Appendix C — Sites Visited and Contacted Bureau of Indian Affairs / Bureau of Indian Education Antelope Dam, SD Beclabito Day School, Beclabito, NM Blackfeet Detention Facility, Browning, MT Captain Tom Dam, NM Chinle Agency Office, Chinle, AZ Chinle Boarding School, Many Farms, AZ Crow Dam, MT Division of Natural Resources, Branch of Irrigation, Power, and Safety of Dams, Denver, CO Great Plains Region, Aberdeen, SD* Haskell Indian Nations University, Lawrence, KS* Headquarter Offices, Washington, DC Jeehdeez’a Academy, Pinon, AZ Kayenta Boarding School, Kayenta, AZ Keams Canyon Elementary, Keams Canyon, AZ Kinlani Bordertown Dormitory, Flagstaff, AZ Little Singer Community School, Winslow, AZ Medicine Root Detention Center, Kyle, SD* Navajo Regional Office, Gallup, NM* Office of Facilities, Environmental, Safety, and Cultural Resources—Facilities Management, Reston, VA Oglala Community School, Pine Ridge, SD Okreek School, Okreek, SD Pine Ridge Detention Center, Pine Ridge, SD Safety of Dams Complex, Ronan, MT Sanostee Day School, Sanostee, NM Santa Ana Dam, NM Sherman Indian School, Riverside, CA Shonto Preparatory School, Shonto, AZ South Okreek Dam, SD Southwest Region, Albuquerque, NM Tuba City Boarding School, Tuba City, AZ Weber Dam, NV Western Navajo Juvenile Corrections Facility, Tuba City, AZ Western Navajo Region, Phoenix, AZ* Bureau of Land Management California State Office, Sacramento, CA Colorado State Office, Lakewood, CO Division of Engineering and Environmental Services, Washington, DC and Lakewood, CO Gunnison Field Office, Gunnison, CO Headquarters Offices, Washington, DC Nevada State Office, Reno, NV Wyoming State Office, Cheyenne, WY Bureau of Reclamation Albuquerque Area Office, Albuquerque, NM McCook Field Office, McCook, NE* Mid-Pacific Regional Office, Sacramento, CA Northern California Area Office, Shasta, CA Safety and Occupational Health Office, Lakewood, CO U.S. Fish and Wildlife Service Jackson National Fish Hatchery, WY Klamath Falls Fish and Wildlife Office, Klamath Falls, OR Little White River Dam, SD Lower Klamath National Wildlife Refuge, OR Modoc National Wildlife Refuge/Dorris Dam, CA National Elk Refuge, WY Headquarters Offices, Washington, DC Sacramento National Wildlife Refuge Complex, CA Tule Lake National Wildlife Refuge, CA Two Ponds National Wildlife Refuge, CO* Natinal Park Service Bent’s Old Fort National Historic Site, CO* Dinosaur National Monument, CO and UT Everglades National Park, FL* Gateway National Park, NY* Glacier National Park, MT Grand Canyon National Park, AZ Grand Teton National Park, WY Headquarters Offices, Washington, DC Inter-Mountain Regional Office, Lakewood, CO Rocky Mountain National Park, CO Yellowstone National Park, WY* Yosemite National Park, CA Departmental Offices Policy, Management and Budget Office of Acquisition and Property Management, Washington, DC Office of Budget, Washington, DC Office of Occupational Health and Safety Washington, DC and Lakewood, CO U.S. Geological Survey Wyoming Field Office, Jackson National Fish Hatchery, WY Headquarters Offices, Reston, VA Office of Surface Mining Reclamation and Enforcement Division of Administration, Washington, DC Minerals Management Service Administration and Budget, Washington, DC* Appendix D — Elements of a Well-Designed Health & Safety Program Occupational Safety and Health Act of 1970 and Executive Order 12196 requires Federal agencies to provide a safe and healthful workplace. The applicable regulations are contained in Title 29 of the Code of Federal Regulations, Part 1960. As required by these regulations, the Department should ensure that: The Department's Designated Agency Safety and Health Official (DASHO) reports at the Assistant Secretary level. 29 C.F.R. § 1960.6 The Department's Office of Occupational Health and Safety has an adequate budget and staff to implement the Department's health and safety program. 29 C.F.R. § 1960.6 Each Bureau’s health and safety budget includes appropriate financial and other resources to effectively implement and administer its health and safety program. 29 C.F.R. § 1960.7 Each Bureau has sufficient personnel at all levels, plus funding for administrative costs, travel expenses, and protective equipment to administer its health and safety program. 29 C.F.R. § 1960.7 Each Bureau utilizes health and safety inspectors that are "personnel with equipment and competence to recognize hazards." 29 C.F.R. § 1960.25 Each Bureau inspects each workplace, including office operations, at least annually. 29 C.F.R. § 1960.25 Each Bureau promptly abates all unsafe and unhealthful conditions. 29 C.F.R. § 1960.30 Each Bureau performs a sufficient number of unannounced inspections and unannounced follow-ups to ensure the abatement of hazardous conditions. 29 C.F.R. § 1960.25 Each Bureau posts each Notice of Unsafe or Unhealthful Working Conditions that includes a full description of the unsafe or unhealthful working condition and planned abatement schedule until the deficiency has been abated or for 3 working days, whichever is later. 29 C.F.R. § 1960.26 Each Bureau includes in its health and safety procedures the right of each employee to report unsafe and unhealthful conditions without threat of restraint, interference, coercion, discrimination or reprisal for filing a report. 29 C.F.R. § 1960.46 Each Bureau provides adequate training for all supervisory employees and for safety and health specialists. 29 C.F.R. § 1960.55 and 1960.56 Each Bureau implements career development programs for their occupational safety and health specialists enabling the specialists to meet present and future safety and health program needs. 29 C.F.R. § 1960.56 Each employee serving in a collateral duty safety and health position receives safety and health training within 6 months of assignment. 29 C.F.R. § 1960.57 Each Bureau establishes committees to monitor and assist with its safety and health program. 29 C.F.R. § 1960.37 Bureau safety and health personnel are held accountable for their individual safety and health programs. 29 C.F.R. § 1960.11 Each Bureau recognizes superior performance in discharging safety and health responsibilities by individuals or groups. 29 C.F.R. § 1960.11 In addition, we believe each Bureau should strive to achieve OSHA's Voluntary Protection Program — STAR or MERIT status. Appendix E — Improvements Needed in Department and Bureau Maintenance Programs The Department’s deferred maintenance backlog has been one of its top management challenges for many years. The total backlog as of FY2006 ranges between $9.6 billion and $17.3 billion, and has increased by at least $2 billion since FY2000. The number of unmitigated health and safety issues at the Department’s facilities is directly related to levels of maintenance being performed. When preventive maintenance is not performed, this lack of maintenance results in unmitigated hazards. Although the Department has developed policies for the life-cycle management of assets, we found that in practice, bureaus did not emphasize preventive maintenance. The lack of routine maintenance has significantly contributed to a maintenance backlog and to health and safety deficiencies. A proactive maintenance process — one that emphasizes the role of preventive maintenance — is essential in meeting ongoing maintenance needs and maximizing the useful life of assets. From FY2000 to FY2006, the Department received approximately $5.9 billion in funding for maintenance. Annual funding increased from $657.9 million in FY2000 to $953.5 million in FY2006; an increase of 45 percent. During this period, the Department also received $4.9 billion in construction funding. Some construction funds are used to address deferred maintenance. (Graph - see PDF version) However, the Department lacks a funding strategy that ensures health and safety maintenance issues are timely and effectively addressed. The Department’s funding is not commensurate with its maintenance requirements. We were told that requesting funding to cover the true cost of performing all maintenance has been discouraged over the years because it is believed that the amount is so large that it would not be provided. The preventive maintenance necessary to keep facilities in good condition and reach their expected useful lives is not always done and facilities continue to deteriorate prematurely. Even though funding is not sufficient to cover all maintenance needs, sometimes bureaus are unable to spend what they get. The Department needs a strategy to coordinate funding and spending in order to obtain appropriate funding levels. We noted that certain NPS national parks such as Yosemite and Grand Canyon have developed park asset management plans that contain detailed estimates for performing maintenance. BOR performs maintenance on many of its facilities with funds provided by water users’ payments and is therefore not as dependent on appropriated dollars as other bureaus in the Department. BIA annually distributes funds to BIE schools for preventive maintenance; however, many schools remain in poor condition. Condition Assessments The Department and its bureaus have not completed initial condition assessments for all of their facilities. Condition assessments identify and validate the condition of facilities; result in the identification of maintenance requirements; and help in identifying health and safety deficiencies. This tool or process assists managers in establishing maintenance schedules, estimating budgetary requirements for recurring, component renewal, and deferred maintenance. The condition assessments create the ability to plan, schedule and conduct maintenance and to properly define the scope and cost of repair, improvement, replacement operations, recurring and preventive maintenance, and component renewal activities in the future. The Department’s Asset Management Plan states that condition assessments begin with verification and existence of the asset and then proceed to examination of its condition. The Plan required that all initial comprehensive assessments be completed by the end of FY2006. As of August 2007, however, the Department and bureaus had not completed all of their condition assessments. Department Must Accelerate Implementation of the New Asset Management Plan The Department and its bureaus are implementing a more proactive asset management plan for their constructed infrastructure; however, they must accelerate its implementation and develop a funding strategy to ensure that routine maintenance is performed when needed to help protect the health and safety of employees and the public. If this is not accomplished, facilities will continue to fall into disrepair and the number of health and safety issues will rise. Progress Has Been Made by the Department We noted that the Department and its bureaus have made progress in the maintenance area. The Department and its bureaus are broadening their maintenance philosophy by adopting policies that require a comprehensive or life-cycle approach to managing facilities. The comprehensive asset management plan requires asset management plans be developed for each bureau and for certain other areas, such as major National Parks and BLM State Offices. A Senior Real Property Officer oversees this process. Many of these actions were taken in response to suggestions we made in our 2001 report, Maintaining the Department of the Interior’s Facilities: A Framework for Action (Report No. 2002-I-0008). The following table provides the status of suggestions from that report. Suggested Action 1. Appoint a Departmental Chief Maintenance Officer   Status Not Implemented. The Department has not appointed a Chief Maintenance Officer. However, the Department does have a Senior Real Property Officer as required by Executive Order 13327. Suggested Action  2. Take immediate steps to reduce the deferred maintenance backlog   Status: Partially Implemented. Over the last 5 years, the bureaus have funded in excess of $5 billion to address deferred maintenance.  In 2005 and 2006, the Department and bureaus reported having initiated or completed 2,365 deferred maintenance projects.  Management cites that it completed 6,000 projects in the National Park Service (NPS) since 2001. Despite these steps, the deferred maintenance backlog has continued to grow. Suggested Action  3. Manage facilities proactively   Status: Partially Implemented. Although the Department and its bureaus are implementing a more proactive asset management plan for their constructed infrastructure; not all bureaus are proactively maintaining their facilities. The Department and bureaus must accelerate the implementation of the asset management plan and develop a funding strategy to ensure that routine maintenance is performed. 4. Establish a single maintenance budget for the entire Department Status: Not Implemented. The Department has not established a single maintenance budget. 5. Conduct standardized condition assessments   Status: Partially Implemented. The Department and its bureaus are establishing better inventories and are in the process of completing condition assessments on their assets. They are also implementing a facility condition index to assist in rating and comparing the condition of different assets.   6. Establish relevant performance measures   Status: Implemented. In its Asset Management Plan, the Department has established goals related to deferred maintenance. Department-wide goals for deferred maintenance reduction have also been established in the Government Performance and Results Act (GPRA) Strategic Plan.   7. Implement an integrated facilities management system   Status: Partially Implemented. The Department and its bureaus are in the process of implementing MAXIMO, a facilities management system, to varying degrees; however, an integrated Department-wide facilities management system is still needed. Appendix F — Bureau Survey Results Chart (see PDF version) Appendix G — List of Figures Figure 1 Survey Response Rate by Bureau 16 Figure 2 Respondents’ Area of Occupation 17 Figure 3 Workplace Description 17 Figure 4 Results of Question Related to Uncorrected Health and Safety Deficiencies 18 Figure 5 Results of Questions Related to Reporting and Mitigation 22 Figure 6 Results of Questions Relating to Health and Safety as a Priority23 Figure 7 Results of Questions Related to High Hazard 24 Appendix H— Abbreviations AMT Asset Management Team BIA Bureau of Indian Affairs BIE Bureau of Indian Education BLM Bureau of Land Management BOR Bureau of Reclamation CASHE Compliance Assessment - Safety, Health, and the Environment CFR Code of Federal Regulations CRV Current Replacement Value DASHO Designated Agency Safety and Health Official Department and DOI Department of the Interior DO Departmental Offices FBMS Financial and Business Management System FWS U.S. Fish and Wildlife Service FY Fiscal Year GAO Government Accountability Office GPRA Government Performance and Results Act MMS Minerals Management Service NBC National Business Center NFH National Fish Hatchery NPS National Park Service OHS Office of Occupational Health and Safety OIG Office of Inspector General OMB Office of Management and Budget OSHA Occupational Safety and Health Administration OSM Office of Surface Mining Reclamation and Enforcement PPE Personal Protective Equipment SMIS Safety Management Information System USGS U.S. Geological Survey Appendix I Department’s Response to the Draft Report (see PDF version) Appendix J Status of Audit Recommendations Recommendations: 1 Status: Resolved and Implemented Action Required: No further action required. Recommendations: 2, 3, 4, 5, 6, 7 Status: Resolved, Not Implemented Action Required: No further response to the Office of Inspector General is needed. We will refer the recommendations to the Assistant Secretary for Policy, Management and Budget for tracking of implementation. _______________________________ Back Cover Page: Report Fraud, Waste, Abuse and Mismanagement Fraud, waste, and abuse in government concerns everyone; Office of Inspector General staff, Departmental employees, and the general public. We actively solicit allegations of any inefficient and wasteful practices, fraud, and abuse related to Departmental or Insular area progrmas and operations. You can report allegations to use in several ways. By Mail: U.s. Department of the Interior Office of Inspector General Mail Stop 5341 MIB 1849 C Street, NW Washington, DC 20240 By Phone: 24-hour Toll Free: 800-424-5081 Washington Metro Area: 703-487-5435 By Fax: 703-487-5402 By Internet: www.doioig.gov