Federal Reports

What We Looked AtThe Federal Aviation Administration’s (FAA) modernization of its National Airspace System (NAS) includes a plan to update the Agency’s aging voice switches with a voice-over internet protocol (VoIP) system. In August 2012, FAA awarded a contract to the Harris Corporation (Harris) to provide the NAS Voice System (NVS), but in December 2018, FAA and Harris agreed to terminate the contract, and FAA still depends on outdated voice communication. In response to a request from the Ranking Members of the U.S. House Committee on Transportation and Infrastructure and its Subcommittee on Aviation, we initiated this audit to assess (1) FAA’s reasons for terminating the NVS contract with Harris and NVS costs and expected benefits and (2) the information on NVS development that the Program Office provided to FAA management and Congress.What We FoundChanges in requirements and schedule delays led to the contract’s termination, and expenditures achieved few benefits. FAA lacked confidence that Harris’s demonstration systems would support VoIP communication in a substantial portion of the NAS. However, the issues with Harris’s systems stemmed in part from changes in FAA’s requirements. Since the termination, FAA has identified reasons for the contract’s failure and lessons learned from the NVS program. FAA spent $160 million on NVS and will spend $274 million to sustain its legacy switches. These expenditures have achieved few benefits. FAA’s Contracting and Program Offices raised performance concerns but delayed taking action. According to FAA, Harris was trying to stabilize its demonstration system. Because FAA would incur little cost from these efforts, allowing Harris to continue made more sense than ending the contract. Finally, FAA did not inform Congress until after contract termination because program costs and schedule variances did not exceed the thresholds required for such notification. RecommendationsFAA concurred with our recommendation to improve the Agency’s future modernization efforts and provided appropriate actions and completion dates. We consider the recommendation resolved but open pending completion of planned actions. 

Ensuring that NASA has an adequate number of astronauts with the skills needed for missions to the International Space Station and the Moon is critical to meeting the Agency’s ambitious space exploration goals. In this report, we examined NASA’s management of its astronaut corps.

The Office of the Inspector General OIG audited the Tennessee Valley Authority’s (TVA) use of remote application and desktop virtualization due to the risk of increased remote users during the COVID-19 pandemic and recent publicized remote access vulnerabilities. We found several areas where TVA was consistent with cybersecurity remote access best practices. However, we identified gaps in TVA’s configuration settings, architectural design, and administrative procedures. We recommend the Vice President and Chief Information and Digital Officer, Technology & Information, review the identified gaps and remediate as appropriate. Specifics of the identified issues were omitted from this report due to their sensitive nature in relation to TVA’s cybersecurity but were formally communicated to TVA management in a briefing on November 15, 2021.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Charles George VA Medical Center in Asheville, North Carolina. The inspection covers key clinical and administrative processes associated with promoting quality care, focusing on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Medication Management: Remdesivir Use in VHA; Mental Health: Emergency Department and Urgent Care Center Suicide Risk Screening and Evaluation; Care Coordination: Interfacility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior.At the time of the OIG inspection, the acting Director had been in the position for two days, but the Associate Director for Patient Care Services/Nurse Executive had been in the role for over 18 years, with other leaders in their roles for over a year. Employee survey responses demonstrated satisfaction with leadership and the workplace. Patient experience survey data implied satisfaction with the care provided, and selected survey results were generally more favorable than those for VHA patients nationally.The OIG’s review of the system’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. Executive leaders were knowledgeable within their scope of responsibilities and tenure about selected VHA data used by the Strategic Analytics for Improvement and Learning models.The OIG issued five recommendations for improvement in two areas:(1) Care Coordination• Inter-facility patient transfer monitoring and evaluation• Transfer form completion• Medication list transmission(2) High-Risk Processes• Disruptive behavior committee meeting attendance• Staff training