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NASA Procedures and Guidelines

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NPR 8621.1A
Effective Date: February 11, 2004
Cancellation Date: July 22, 2010
Responsible Office: GA

NASA Procedural Requirements for Mishap Reporting, Investigating, and Recordkeeping


ALL

CHAPTER 1. General Information


1.1 Objectives of NASA Mishap and Close Call Investigations

The objective of mishap and close call investigations is to improve safety by identifying what happened, where it happened, when it happened, why it happened, and what should be done to prevent recurrence and reduce the number and severity of mishaps.

1.2 Description of NASA Mishaps and Close Calls

1.2.1 NASA Mishap. An unplanned event that results in at least one of the following:

1.2.1.1 Injury to non-NASA personnel, caused by NASA operations.

1.2.1.2 Damage to public or private property (including foreign property), caused by NASA operations or NASA-funded development or research projects.

1.2.1.3 Occupational injury or occupational illness to NASA personnel.

1.2.1.4 NASA mission failure.

1.2.1.5 Destruction of, or damage to, NASA property.

1.2.2 The following are not considered NASA mishaps.

1.2.2.1 A malfunction or failure of component parts that are normally subject to fair wear and tear and have a fixed useful life that is less than the fixed useful life of the complete system or unit of equipment, provided that all of the following are true:

a. There was adequate preventative maintenance.

b. The malfunction or failure was the only damage, and the sole action is to replace or repair that component. (This exception does not apply to a malfunction or failure of a component part that results in damage to another component or the facility or injury to personnel.)

1.2.2.2 A test failure involving damage to equipment or property as a result of testing, provided that all of the following are true:

a. The test article is not flight hardware.

b. The testing is part of an authorized research/development/qualification/certification program.

c. Damage is limited to the test article and test instrumentation.

d. Risk of damage to the test article and test instrumentation resulting from failure was accepted explicitly (i.e., documented) by program/project management and concurred on by the Center safety office.

e. The test team performs a test failure analysis and generates a technical report instead of treating it as a mishap and completing a mishap report.

1.2.3 Close Call. An occurrence or a condition of employee concern in which there is no injury or only minor injury requiring first aid and no significant equipment/property damage (less than $1000), but which possesses a potential to cause a mishap.

1.2.4 NASA property damage or personnel injuries that are the result of vandalism, riots, civil disorders, or felonious acts such as arson or sabotage are not considered NASA mishaps. These incidents should be reported and investigated in accordance with procedures under NPD 9800.1, NASA Office of Inspector General Programs, and NPR 1620.1, Security Procedural Requirements.

1.3 Determining the Classification Level and Type of Investigation to be Conducted

1.3.1 The severity of the personnel injury and the direct cost of the mishap (property damage and/or mission failure) shall determine the classification level of the mishap or close call (see Figure 1) and the corresponding type of investigation to be conducted (Requirement 31069).

1.3.2 When the Administrator, Associate Administrator, Office of Safety and Mission Assurance (AA/OSMA), the Designated Agency Safety and Health Official (DASHO), Center Director (CD), or the Director, Headquarters Operations, Office of Institutional and Corporate Management (Director, HQ Ops.), believes that the mishap or close call is a high visibility event, he/she may elevate the mishap classification and level of investigation to the classification he/she deems appropriate and may request that the Enterprise Associate Administrator (EAA) form a Mishap Investigation Board (MIB).

1.3.3 Determining the direct cost of the mishap (for the purpose of mishap classification).

1.3.3.1 The direct cost of a mishap shall be calculated by adding all costs (the greater value of actual or fair market value) of damaged property, destroyed property, or mission failure, actual cost of repair or replacement, labor (actual value of replacement or repair hours for internal and external/contracted labor), cost of the lost commodity (e.g., the cost of the fluid that was lost from a ruptured pressure vessel), as well as resultant costs such as environmental decontamination, property cleanup, and restoration, or the best official estimate of these costs (Requirement 31072).

1.3.3.2 In cases where replacement parts are available from salvaged or excess equipment at little or no cost to NASA, the direct cost of the mishap shall include the actual costs of replacement parts (if they were purchased new) plus labor calculated as if the salvage/excess parts were unavailable (Requirement 31073).

1.3.3.3 Determination of direct cost shall not take into consideration any insurance compensation, contractor compensation, or other compensation (Requirement 31074).

1.3.3.4 The cost of the safety mishap investigation shall not be included in the direct cost (Requirement 31075).

Figure 1. Mishap Classification Levels and Type of Investigation to be Conducted

Classification Level & Investigation Type

Property Damage

Injury

Type A Mishap

Total direct cost of mission failure and property damage is $1,000,000
or
more,orCrewed aircraft hull loss has occurred,
or
Occurrence of an unexpected aircraft departure from controlled flight (except high performance jet/test aircraft such as F-15, F-16, F/A-18, T-38, and T-34, when engaged in flight test activities).

Occupational injury and/or illness that resulted in:

A fatality,
or
A permanent total disability,
or
The hospitalization for inpatient care of 3 or more people within 30 workdays of the mishap.

Type B Mishap

Total direct cost of mission failure and property damage of at least $250,000 but less than $1,000,000.

Occupational injury and/or illness has resulted in permanent partial disability.
or
The hospitalization for inpatient care of 1-2 people within 30 workdays of the mishap.

Type C Mishap

Total direct cost of mission failure and property damage of at least $25,000 but less than $250,000.

Nonfatal occupational injury or illness that caused any workdays away from work, restricted duty, or transfer to another job beyond the workday or shift on which it occurred.

Type D Mishap

Total direct cost of mission failure and property damage of at least $1,000 but less than $25,000.

Any nonfatal OSHA recordable occupational injury and/or illness that does not meet the definition of a Type C mishap.

Close Call

Total direct cost of mission failure and property damage is less than $1,000
or
An occurrence or condition of employee concern in which there is no property damage but possesses the potential to cause a mishap.

Minor injury requiring first aid which possesses the potential to cause a mishap
or
An occurrence or condition with no injury but possesses the potential to cause a mishap.

1.4 Roles and Responsibilities

1.4.1 Administrator. The Administrator:

a. May elect to be the appointing official for Type A mishaps. (If the Administrator elects not to be the appointing official, he shall designate the EAA or another designee to serve as the appointing official.) (Requirement 31078).

b. Shall serve as appointing official for NASA joint participation on a MIB with the Department of Defense (DoD) and other agencies unless authority is delegated by existing agreements (Requirement 31079).

c. May elect to be an endorsing official for Type A mishaps and other mishaps in which he is the appointing official.

1.4.2 AA/OSMA. The AA/OSMA or designee shall:

a. Ensure the proper reporting, investigating, and recordkeeping for mishaps and close calls by defining the mishap reporting and investigating process, updating this NPR, verifying its implementation, developing mishap investigation training, and identifying candidate mishap investigation tools (Requirement 31082).

b. Concur with the mishap classification level, investigation approach, and the MIB membership, and serve as an endorsing official for the mishap report for Type A mishaps, Type B mishaps, high visibility mishaps, and high visibility close calls (Requirement 31083).

1.4.3 Inspector General. The Inspector General shall investigate criminal activity associated with mishaps and close calls (Requirement 31084).

1.4.4 EAA. The EAA shall:

a. Implement the mishap reporting, investigating, and recordkeeping requirements for their assigned Enterprisesv (Requirement 31086).

b. Develop pre-mishap plans to support this NPR (Requirement 31087). (This includes procedures to notify, report, investigate, and record ishaps and close calls that involve Enterprise programs/projects/activities that are not managed by a Center, program, or project, where the mishap or close call has occurred outside the Center's gates.) (Requirement 31088).

c. Concur with the mishap classification level for Type A mishaps, Type B mishaps, high visibility mishaps, and high visibility close calls (Requirement 31089).

d. Serve as the appointing official for Type A mishaps when designated by the Administrator, and serve as the appointing official for high visibility mishaps and high visibility close calls (Requirement 31090).

e. Serve as the appointing official (or assign a designee to serve as the appointing official) for Type B mishaps, Type C mishaps, Type D mishaps, and close calls that involve Enterprise programs/projects/activities that are not managed by a Center, program, or project, where the mishap or close call has occurred outside the Center's gates (Requirement 31091).

f. Obtain concurrence from the AA/OSMA on the MIB membership of Type A mishaps, high visibility mishaps, and high visibility close calls in which he/she is the appointing official (Requirement 31092).

g. Serve as an endorsing official for Type A mishaps, high visibility mishaps, and high visibility close calls in which he/she is the appointing official (Requirement 31093).

h. Provide funding and support for investigations at their Centers, within their programs, and involving their hardware, facilities, or enabling activities (Requirement 31094).

1.4.5 Assistant Administrator, Office of Public Affairs (AA/OPA). The AA/OPA:

a. Shall establish guidelines for the public release of mishap reports and related information (Requirement 31096).

b. With the assistance of the Center safety office, Interim Response Team (IRT), investigating authority, and CD or Director, HQ Ops., the AA/OPA shall release information to the press and media (i.e., potential hazards that may affect the public, interim reports, and the authorized mishap report) (Requirement 31097).

c. For Type A mishaps, Type B mishaps, Type C mishaps, high visibility mishaps, and high visibility close calls, the AA/OPA shall appoint a Headquarters public affairs advisor (Requirement 31098). (For Type B mishaps and Type C mishaps, the AA/OPA may delegate authority to appoint a public affairs advisor to the Center Public Affairs Office [PAO].)

1.4.6 CD and Director, HQ Ops. The CD and the Director, HQ Ops., shall:

a. Develop and document a Center pre-mishap plan that is consistent with this NPR and includes local policies and procedures for mishap reporting, investigation, recording, and prevention (Requirement 31100). (This includes pre-mishap planning for operational aircraft, e.g., T-38, B-747, helicopter, balloon, and others, that are fielded at the Center.)

b. Determine the mishap classification level for all mishaps occurring at, or managed by, his/her Center and obtain concurrence on this classification level from the AA/OSMA and the EAA for Type A mishaps, Type B mishaps, high visibility mishaps, and high visibility close calls (Requirement 31101).

c. Serve as the appointing official for Type B mishaps, Type C mishaps, Type D mishaps, and close calls occurring at, or managed by, his/her Center. (The CD or Director, HQ Ops., may delegate the role of appointing official to an official one level down from his/her position for Type C mishaps, Type D mishaps, and close calls.) (Requirement 31102).

d. Obtain concurrence from the AA/OSMA on the MIB membership of Type B mishaps in which he/she is the appointing official (Requirement 31103).

e. Provide administrative and logistical support for the investigating authority working on the Center and distribute the authorized mishap report per this NPR (Requirement 31104).

f. Verify that NASA contractors and grantees conduct mishap investigations and provide mishap reports as specified in their contracts and in NFS 1852.223-70 (Requirement 31105).

g. Serve as an endorsing official for mishaps and close calls in which he/she is the appointing official (Requirement 31106).

1.4.6.1 The Director, HQ Ops., shall provide funding and support for investigations of mishaps that occur at NASA Headquarters that do not involve Enterprise programs, projects, or activities (Requirement 31107).

1.4.7 Program and Project Managers. Program and project managers shall:

a. Develop a program/project pre-mishap plan (Requirement 31109). (This is applicable to all programs. Programs with aircraft in the developmental, qualification, or certification phases of the program shall have a program pre-mishap plan that is tailored for the particular phase of the program.) (Requirement 31110).

b. In the event of a mishap, activate the program pre-mishap plan, if appropriate (Requirement 31111).

c. Provide funding and support for investigations within their program jurisdiction or involving their hardware and facilities (Requirement 31112).

d. Assist the investigating authority as requested (Requirement 31113).

e. When tasked by the appointing official, develop the Corrective Action Plan (CAP), implement the CAP, support the Center safety office personnel as they verify that the CAP has been completed, and generate the lessons learned (Requirement 31114).

1.4.8 Responsible Organization. The responsible organization shall:

a. Assist the investigating authority as requested (Requirement 31116).

b. When tasked by the appointing official, develop the CAP, implement the CAP, support the Center safety office personnel as they verify that the CAP has been completed, and generate the lessons learned (Requirement 31117).

1.4.9 Appointing Official. The appointing official shall:

a. Use this NPR to determine the type of investigating authority (i.e., MIB, Mishap Investigation Team [MIT], or Mishap Investigator [MI]) that will investigate a mishap or close call or, alternately, whether NASA will accept the investigation and subsequent mishap report of another competent authority that may have jurisdiction (Requirement 31119).

b. Determine the level of NASA involvement, if any, when a mishap resulted from the actions of an outside source that was not involved in NASA operations (Requirement 31120).

c. Initiate a NASA investigation pursuant to this NPR, when the appointing official believes that a NASA contractor's/grantee's mishap report is not adequate because it failed to reach root cause(s), failed to provide recommendations that prevent recurrence, is not suitably independent, or is in some other way deficient (Requirement 31121).

d. Generate a formal memorandum for Type A mishaps, Type B mishaps, high visibility mishaps, and high visibility close calls that communicates the appointment of the investigating authority members, the chairperson, the ex officio representative, and the support staff (Requirement 31122). (For Type C mishaps, Type D mishaps, and close calls, the appointment orders can be less formal and communicated via a Center process.)

e. Serve as an endorsing official for mishaps and close calls in which he/she is the appointing official (Requirement 31123).

f. Assign the responsible organization(s)/program(s)/project(s) to develop the CAP, implement the CAP, and generate the lessons learned (Requirement 31124).

g. Ensure that the mishap investigation process for the assigned mishap or close call is properly completed (Requirement 31125).

h. Verify that the mishap report is reviewed, endorsed, and authorized for public release (Requirement 31126).

i. Ensure that the CAP is developed and implemented (Requirement 31127).

j. Ensure that the lessons learned are developed, reviewed, and authorized for public release (Requirement 31128).

k. Release the investigating authority from duty (Requirement 31129).

l. Generate the CAP closure statement and the mishap investigation completion statement (Requirement 31130).

m. If the NTSB performs an investigation, the appointing official shall:

(1) Initiate a NASA mishap investigation per this NPR (Requirement 31132).

(2) Request that a NASA representative be a party to the NTSB's investigation (Requirement 31133).

n. Assist the investigating authority as requested (Requirement 31134).

1.4.10 Endorsing Official. The endorsing official shall review the mishap investigation report and provide a signed written endorsement, comments, and a recommendation as to whether the mishap report should be approved or rejected (Requirement 31135). (This endorsement and any comments shall be attached to the mishap report and become part of the permanent record.) (Requirement 31136).

1.4.11 Ex Officio Representative. The ex officio representative shall:

a. Serve as the authorized representative of the AA/OSMA (Requirement 31138).

b. Be a nonvoting participant in all investigation deliberations (Requirement 31139).

c. Participate in all investigation proceedings as he/she deems appropriate (Requirement 31140).

d. Assure that the investigation is conducted in conformance with NASA policy and this NPR and the investigation process is fair, independent, and nonpunitive (Requirement 31141).

e. Assure that the mishap report contains the proper elements including proximate cause(s), root cause(s), failed barrier(s), and observation(s); sufficient facts/data to support the finding(s) and recommendation(s); and a mishap investigation summary (Requirement 31142).

f. Sign the final mishap report demonstrating his/her belief that paragraph 1.4.11 sections a-d of this NPR have been satisfied or attach a signed written description of the report's deficiencies (Requirement 31143).

g. For Type A mishaps, Type B mishaps, high visibility mishaps, and high visibility close calls, provide the AA/OSMA interim briefings on the status of the investigation, upon his/her request (Requirement 31144).

1.4.12 Chairperson. The chairperson of the investigating authority shall:

a. Manage and coordinate all aspects of the mishap investigation, including, but not limited to, the following tasks: assign group leaders; impound data, records, equipment and facilities; collect/salvage data and debris; analyze data; interview witnesses; reconstruct the mishap or close call; identify facts; identify proximate cause(s) and root cause(s); generate recommendation(s); complete the mishap report; and release the impounded data, records, equipment, facilities, and mishap site (Requirement 31146).

b. Define the roles and/or areas of investigative responsibility for each group or subgroup on his MIB or MIT, as needed (Requirement 31147).

c. Coordinate with the investigating authority's legal advisor, Headquarters or Center public affairs advisor, and import/export control advisor throughout the investigation (Requirement 31148).

d. Report only to the appointing official or his/her representative during the investigation (Requirement 31149).

e. Refer allegations and evidence of criminal activity that are identified in the course of an investigation to the Office of Inspector General. Privileged witness statements will be protected to the extent provided by law (Requirement 31150).

1.4.13 Investigating Authority. The investigating authority shall conduct a comprehensive investigation within the defined scope of the appointment letter or appointment orders, generate the products indicated in paragraph 1.7 and Figure 5 of this NPR, prepare a mishap report, and sign the report (Requirement 31151).

1.4.14 Investigating Authority's Advisors. The advisors shall:

a. Attend meetings as needed, have access to all investigative material with the exception of witness statements, and travel with the investigating authority as requested (Requirement 31153).

b. Provide advice to the investigating authority (Requirement 31154).

c. Sign the mishap report stating that he/she has reviewed the mishap report; that it meets NASA policies and procedures in his/her functional area; that any privileged, proprietary, International Traffic in Arms Regulations (ITAR) information, Export Administration Regulations (EAR) information, or material subject to the Privacy Act has been identified and marked as nonreleasable to the public; and that sections that are releasable to the public are marked releasable and, to the best of his/her knowledge, are ready for public release (pending endorsements and OPA authorization) (Requirement 31155).

1.4.15 Investigating Authority's Consultants. The consultants should:

a. Provide advice to the investigating authority.

b. Perform analysis, as requested.

c. Assist in formulating conclusions, as requested.

1.4.16 The consultants shall not:

a. Participate in deliberations (vote on findings) (Requirement 31161).

b. Sign the mishap report (Requirement 31162).

c. Read, listen to, or participate in witness interviews unless they are tasked to analyze interviews, and they have signed a nondisclosure agreement prepared by NASA Office of General Counsel (Requirement 31163).

1.4.17 The advisors and consultants may be excluded from listening to any deliberations at the discretion of the chairperson.

1.4.18 IRT. The IRT shall:

a. Conduct initial investigation activities if there is a delay in the initiation of a formal investigation (Requirement 31166).

b. Support rescue efforts as requested by emergency responders (Requirement 31167).

c. Notify the Center PAO about casualties, damages, and any potential hazards to the public, and notify legal advisors (as appropriate) (Requirement 31168).

d. Assist the incident commander as he/she safes and secures the mishap site, as requested (Requirement 31169).

e. Preserve evidence, document the scene, identify witnesses, and support the Center safety office in impounding data and collecting witness statements (written statements when possible) (Requirement 31170).

f. Advise the supervisor if drug testing should be requested (Requirement 31171).

g. Provide all available mishap data and evidence to the investigating authority (Requirement 31172).

1.4.19 Incident Commander. The incident commander shall implement the procedures outlined in the Center pre-mishap plan to coordinate rescue activities, mitigate hazards, and safe and secure the mishap site (Requirement 31173).

1.4.20 Center Safety Office . The Center safety office shall:

a. Support the development of the Center pre-mishap plan, program pre-mishap plan(s), contract clauses, mishap investigation training, and a mishap investigation tool repository (that makes tools readily accessible to investigating authorities) (Requirement 31175).

b. Ensure that their Center's employees are familiar with the roles and responsibilities as documented within the Center pre-mishap plan and this NPR (Requirement 31176).

c. Implement the Center pre-mishap plan; when applicable, support the program as they initiate the program pre-mishap plan; and initiate, facilitate, and coordinate all investigation activities per the plan (Requirement 31177).

d. Report the mishap to Headquarters per the reporting requirements defined in this NPR and to OSHA (when applicable) (Requirement 31178).

e. Support the incident commander as he/she safes and secures the mishap site (Requirement 31179).

f. Impound data, records, equipment, and facilities (Requirement 31180).

g. Advise the supervisor that drug testing should be initiated (Requirement 31181).

h. Collect witness statements (written statements preferred) (Requirement 31182).

i. Ensure that mishap and close call information is entered in the Incident Reporting Information System (IRIS) per the requirements outline in this NPR (Requirement 31183).

j. Verify the CAP is complete and all elements of the investigation have been completed (Requirement 31184).

k. Retain mishap investigation records per NPR 1441.1 and physical evidence (debris) as necessary. (Requirement 31185)

l. Keep an updated list of all Center personnel that have training and experience in mishap investigation including information such as relevant training courses, date of training, recent participation in a mishap investigation, and security clearances. (Requirement 31186)

m. Establish a Center-specific process to disseminate to other Centers, the final mishap report, and to rapidly disseminate preliminary mishap and close call precautionary information that meets the PAO guidelines for release. (Requirement 32596)

1.4.21 Security. Security shall support the Center safety office in securing the mishap site and impounding data, records, equipment, and facilities. (Requirement 31187)

1.4.22 Supervisors. Supervisors shall:

a. Notify the Center safety office when a mishap or close call occurs. (Requirement 31189)

b. Support the incident commander as he/she secures and safes the mishap site. (Requirement 31190)

c. Initiate drug testing after a mishap if the mishap results in a fatality, or personal injury requiring immediate hospitalization, or in damage estimated to be in excess of $10,000 to government or private property. (Requirement 31191)

d. Assist the investigating authority, as requested. (Requirement 31192)

e. Complete the initial mishap or close call report in accordance with the Center pre-mishap plan. (Requirement 31193)

1.4.23 All Employees. All employees shall:

a. If witness to, or involved in, a NASA mishap or close call, immediately notify both emergency response (e.g., 911, fire, ambulance, security) of the need for assistance and a supervisor, management official, or a safety/health staff member of the circumstance of the mishap or close call. (Requirement 31195)

b. Complete witness statements prior to leaving the mishap investigation site, to the extent possible. (Requirement 31196)

c. Provide as much information as possible to the investigating authority. (Requirement 31197)

1.4.24 Center's Chief of Aircraft Operations . The Chief of Aircraft Operations shall notify the NTSB of a mishap involving aircraft per paragraph 1.6.5 of this NPR and complete NTSB Form 6120 per paragraph 1.6.7 of this NPR and NTSB requirements. (Requirement 31198)

1.4.25 Contracting Officers . Contracting officers shall:

a. Involve the Center safety office in the acquisition strategy planning activities for proposed contracts as detailed in NASA NFS Part 1807, "Acquisition Planning." (Requirement 31200)

b. Incorporate applicable mishap and close call reporting and investigating procedures and corrective action requirements detailed in the NFS into contracts and grants covering NASA programs and operations. (Requirement 31201)

1.4.26 Chief Health and Medical Officer (CHMO). For Type A mishaps, Type B mishaps, high visibility mishaps, and high visibility close calls involving an injury or fatality, the CHMO shall serve as an endorsing official. (Requirement 31202)

1.4.27 Office of Institutional and Corporate Management, Infrastructure and Management Office, Aircraft Management Office (AMO) . For Type A mishaps, Type B mishaps, high visibility mishaps, and high visibility close calls involving aircraft, AMO shall serve as an endorsing official. (Requirement 31203)

1.4.28 Office of the General Counsel. The Office of General Counsel shall:

a. Develop and implement procedures for collateral investigations that will be performed for mishaps and close calls that do not involve criminal activity. (Requirement 31205)

b. Assist the AA/OPA (or designee) in the review of the approved mishap report as it is being prepared for public release. (Requirement 31206)

1.4.29 Roles and responsibilities are summarized in Figure 2.

Figure 2.  Mishap Organizational Responsibilities Matrix border=

 

1.5 Notification and Reporting Requirements

1.5.1 Immediately after a mishap or close call, NASA employees shall notify the appropriate authorities, in the manner specified in paragraph 1.4.23 of this NPR and the Center pre-mishap plan. (Requirement 31209)

1.5.2 The Center safety office shall collect employee safety concerns, mishap reports, and close call reports through a Center process, review the employee reports, verify that they meet the definitions of mishap or close call found in Appendix A and Figure 1, and report those that are consistent with the NPR. (Requirement 31210)

1.5.3 Notify Office of Safety and Mission Assurance, Safety and Assurance Requirements Division (HQ Code QS) . After emergency response has been initiated, within one hour of the occurrence of a Type A mishap, Type B mishap, high visibility mishap, or high visibility close call, the Center safety office shall notify HQ Code QS by calling 1.202.358.0006, or, if no answer, by calling the NASA Headquarters After Hours Contact Center at 1.866.230.6272. (Requirement 31211) Mishap notification must be acknowledged (verbally, e-mailed, or faxed) to meet the intent of this requirement. (Requirement 31212) (Per NPR 7100.1, paragraph 11.4.1, this includes immediately reporting a human test subject injury or fatality that resulted in a loss of life, a permanent disability, hospitalization, extensive first aid, or lost workday[s].) (Requirement 31213)

1.5.3.1 During this notification, the Center safety office shall provide the following information: the Center name, location of incident, time of incident, number of fatalities (if known), number of hospitalized employees (if known), type of injury (if known), type of damage (if known), contact person, contact person's phone number, and a brief description of the mishap. (Requirement 31214)

1.5.3.2 Within 24 hours of a Type A mishap, Type B mishap, high visibility mishap, or high visibility close call, the Center safety office shall follow up the initial phone notification by sending an electronic notification to HQ Code QS that includes the following information: Center submitting report; author of report; author's phone number and mail code; date report submitted; time report submitted; incident date; incident time; incident general location; exact location (if known); responsible organization; organization's point of contact; point of contact's phone number and mail code; mission affected; program impact (if known); number and type of injuries or fatalities (if known); type of damage to equipment, flight hardware, flight software, or facilities; estimate of direct cost of damage; and a brief description of the mishap or close call. (Requirement 31215)

1.5.4 Notify OSHA. Within 8 hours of a work-related mishap involving death of a Federal employee, or the hospitalization for inpatient care of three or more employees (provided at least one is a Federal employee), the Center safety office shall notify OSHA by calling the area office nearest the site of the mishap or OSHA's toll-free number, 1.800.321.6742 . (Requirement 31216)

1.5.4.1 OSHA notification is required for any fatality or three or more hospitalizations that occur up to 30 workdays after the respective mishap. (Requirement 31217)

1.5.4.2 The Center safety office shall persist in making contact with OSHA to provide this report until OSHA has acknowledged receipt of the report. (Requirement 31218)

1.5.4.3 In notifying OSHA, the Center safety office shall provide OSHA with the following information: the establishment name, location of incident, time of incident, number of fatalities (if known), number of hospitalized employees (if known), contact person, contact person's phone number, and a brief description of the mishap. (Requirement 31219)

1.5.4.4 After notifying OSHA, the Center safety office shall inform HQ Code QS that an oral report has been provided to OSHA. (Requirement 31220)

1.5.5 Report Criminal Activity Associated with NASA Mishaps to the Office of Inspector General and the Office of the General Counsel.

1.5.5.1 The Office of Inspector General (OIG) and the Center's Office of the Chief Counsel or the NASA Office of the General Counsel shall be notified if it is suspected that a mishap resulted from criminal activity. (Requirement 31222)

1.5.5.2 Any facts related to criminal activity in connection with a mishap shall be referred to the OIG. (Requirement 31223) Privileged witness statements will be protected to the extent provided by law.

1.6 Additional Notification and Reporting Requirements for Aircraft Investigations

1.6.1 NASA employees shall report immediately to the Center safety office any of the aircraft mishaps or anomalies described in Figure 3, paragraph 1.2, and paragraph 1.6.2 of this NPR. (Requirement 31225)

Figure 3. NASA Aircraft Close Calls and Mishaps Required to be Reported Immediately to the NTSB

All Aircraft

  • •  Flight control system malfunction or failure.

  • •  All aircraft accidents with substantial damage.

    • Inability of any required flight crewmember to perform normal flight duties as a result of injury or illness.
    • Failure of structural components of a turbine engine, excluding compressor and turbine blades and vanes.
    • In-flight fire.
    • Aircraft collision in flight.
    • Damage to property other than the Agency aircraft.

    For large multiengine aircraft (more than 12,500 pounds maximum certificated take-off weight)

  • •  In-flight failure of hydraulic systems that results in sustained reliance on the sole remaining hydraulic or mechanical system for movement of flight control surfaces.

    • Sustained loss of the power or thrust produced by two or more engines.
    • An evacuation of an aircraft in which an emergency egress system is used.
    • An aircraft is overdue and is believed to have been involved in a mishap or close call.

    Figure 4: Information Required for All Agency Aircraft Mishaps and Close Calls

    1. Type, nationality, and registration marks of the aircraft.

    2. Name of owner and operator of the aircraft.

    3. Name of the pilot in command.

    4. Date and time of the mishap, malfunction, or failure.

    5. Last point of departure and point of intended landing of the aircraft.

    6. Position of the aircraft with reference to some easily defined geographical point.

    7. Number of persons aboard and number killed or seriously injured.

    8. Nature of the mishap or occurrence, the weather, and the extent of damage to the

    aircraft, so far as is known.

    9. A description of any explosives, radioactive materials, or other dangerous articles carried.

    1.6.2 Employees shall report unexpected aircraft departure from controlled flight for all aircraft except the following high performance jet/test aircraft which can experience departure from controlled flight when engaged in flight test activities: F-15, F-16, F/A-18, T-38, and T-34. (Requirement 31228) These aircraft are exempt because it is a common occurrence for a high performance jet/test aircraft that does dynamic maneuvering to depart from controlled flight.

    1.6.3 Immediately after the occurrence of an aviation mishap, or NTSB-defined mishap or close call, the Center aircraft operator shall provide all the information listed in Figure 4 to the Center safety office and the Center Chief of Aircraft Operations. (Requirement 31229)

    1.6.4 The Center safety office shall notify HQ Code QS and AMO of any aircraft mishap or close call as defined by paragraph 1.2, paragraph 1.6.2, and Figure 3 of this NPR, and ensure that all information listed in Figure 4 of this NPR is entered on the appropriate form in IRIS. (Requirement 31230)

    1.6.5 The Center's Chief of Aircraft Operations or his/her designee shall immediately notify the NTSB of any aircraft mishap (as defined in Figure 1 of this NPR), incident, or close call as defined in Figure 3 and paragraph 1.6.2 of this NPR and in accordance with 49 CFR Part 830 and notify HQ Code QS that NTSB notification has been completed. (Requirement 31231)

    1.6.6 In the event that the NTSB exercises its authority to investigate a NASA aircraft mishap, NASA shall conduct a separate investigation in accordance with this NPR. (Requirement 31232)

    1.6.7 Within 10 workdays of an aircraft mishap or close call that meets the reporting requirements as defined in Figure 3 and paragraph 1.6.2 of this NPR, the Center Chief of Aircraft Operations shall submit an NTSB Form 6120 to the NTSB regional office nearest to the location of the mishap or close call. (Requirement 31233)

    1.6.8 An unmanned aerial vehicle (UAV) is not currently considered an aircraft by the NTSB, consequently NTSB reporting requirements are not applicable to a UAV unless personnel are injured or the UAV comes down in a populated area outside a Center's gates.

    1.7 Investigation Product for each Classification Level/Type of Investigation

    1.7.1 The investigating authority shall conduct an investigation and include the following products in the mishap report according to the requirements listed in Figure 5:

    a. Investigating authority and ex officio signatures demonstrating their approval of the mishap report. (Requirement 31237) Advisor(s) signatures demonstrating that he/she has reviewed the mishap report; that it meets NASA policies and procedures in his/her functional area; that any privileged or proprietary information, ITAR information, EAR information, or material subject to the Privacy Act has been identified and marked as nonreleasable to the public; and that sections that are releasable to the public are marked releasable and, to the best of his/her knowledge, are ready for public release (pending endorsements and Headquarters and Center public affairs authorization). (Requirement 31238)

    b. List of the investigating authority's consultants. (Requirement 31239)

    c. An executive summary that does not contain privileged or proprietary information, material subject to the Privacy Act, ITAR information, or EAR information. (Requirement 31240)

    d. The OSHA Final Mishap Summary (OSHA 301 Form: Injury and Illness Incident Report, or an equivalent form), if the mishap is an OSHA recordable incident. (Requirement 31241)

    e. Description of the type of data gathered and evaluated during the investigation. (Requirement 31242)

    f. Narrative description of the facts including what, when, and where. (Requirement 31243)

    g. Timeline. (Requirement 31244)

    h. Description of all structured analysis techniques used and how they contributed to determining the findings. (Requirement 31245)

    i. Event and causal factor tree or similar graphical representation of the mishap. (Requirement 31246)

    j. Description explaining why the mishap/close call occurred including all finding(s) such as proximate cause(s), root cause(s), contributing factor(s), failed barrier(s), observation(s), and the evidence upon which the findings are based. (Requirement 31247)

    k. Conclusions and recommendations. (Requirement 31248)

    l. Minority report, if there is one. (Requirement 31249)

    Figure 5. Classification Level/Investigation Type with Corresponding Appointing Official, Endorsing Officials, and Required Products in the Mishap Report

     

     

    Classification Level & Investigation Type

     

    High Visibility

    Mishap or

    Close Call

     

    Type A

     

    Type B

     

    Type C

     

    Type D

     

    Close Call

    Investigating Authority

     

    MIB1

     

    MIB

    (at least 5 members)

     

    MIB

    (at least 3 members)

     

    MIT or MI

     

    MIT or MI

     

    MIT or MI

    Required Products

    All (a-l) 1

    All (a-l)

    All (a-l)

    a-d, f, j, k, l

    a, f, j, k, l

    a, f, j, k, l

     

    Appointing Official

    EAA1

    Administrator2

    or

    Designee

    or

    EAA

     

    CD

    or

    Director, HQ Ops.

    CD

    or

    Director,

    HQ Ops.,

    or Designee

    or

    EAA Designee6

    CD

    or

    Director,

    HQ Ops.,

    or Designee

    or

    EAA Designee6

    CD

    or

    Director,

    HQ Ops.,

    or Designee

    or

    EAA Designee6

    Concurrence on MIB

    Membership

     

    AA/OSMA1

     

    AA/OSMA

     

    AA/OSMA

     

    _ _ _ _ _

     

    _ _ _ _ _

     

    _ _ _ _ _

    Endorsing

    Officials

    Appointing Official1,

    AA/OSMA1,

    AMO1,3,

    Procurement1,

    CHMO 1,4,

    Other1

    Appointing Official,

    Administrator 2,

    AA/OSMA,

    AMO3,

    CHMO 4,

    Procurement5,

    Other5

    Appropriate EAA,

    Appointing Official,

    AA/OSMA,

    AMO3,

    CHMO4,

    Procurement5,

    Other

    Appointing Official and

    Center Process

    Appointing Official and

    Center Process

    Appointing Official and

    Center Process

    Officials Reviewing Mishap Report Prior to

    Authorization for Public Release

     

    Legal,

    OPA,

    Import/Export Control

     

    Legal,

    OPA,

    Import/Export Control

     

    Legal,

    OPA,

    Import/Export Control

     

    Center PAO

    Import/Export Control,

    and

    Center Process

     

    Center PAO,

    Import/Export Control,

    and

    Center Process

     

    Center PAO,

    Import/Export Control,

    and

    Center Process

    KEY

     

    1 = Occurs when the EAA determines that the high visibility mishap or high visibility close call should be

    investigated by a MIB.

    2 = Only when Administrator desires.

    3 = Only when the mishap or close call involves an aircraft.

    4 = Only when the mishap or close call involves an injury or fatality.

    5= When needed.

    6 = When the mishaps or close calls involve Enterprise programs/projects/activities that are not managed by a Center, program, or project, where the mishaps or close calls have occurred outside the Center's gates.

     

     

     

     

     

     

     

     

     

     

     

    1.7.2 For close calls, where the potential for a Type A mishap or Type B mishap is significant, the Center Safety and Mission Assurance (SMA) director may consider application of a MIB or MIT investigation and their associated products. Serious workplace hazards previously unidentified and discovered as a result of inspections, audits, surveys, or concerns shall be investigated in the same manner as close calls.

     

    1.7.3 The CD or Director, HQ Ops., shall elevate the level of investigation and required products of any mishap or close call upon the request of a higher authority, such as the Administrator, an Associate or Assistant Administrator, or upon his/her discretion.

     

    1.8 Recording Requirements

     

    1.8.1 Within 24 hours, the Center safety office shall ensure that all NASA mishaps and close calls are recorded in IRIS and include the following information: Center submitting report; author of report; author's phone number and mail code; date report submitted; time report submitted; incident date; incident time; incident general location; exact location (if known); responsible organization; organization's point of contact; point of contact's phone number and mail code; mission affected; program impact (if known); number and type of injuries or fatalities (if known); type of damage to equipment, flight hardware, flight software, or facilities; estimate of direct cost of damage; and a brief description of the mishap or close call.

     

    1.8.2 For mishaps or close calls involving injury, the occupational health representative or other medical person shall provide the appropriate medical information regarding the person(s) injured and the nature of the injury(s) to the Center safety office for inclusion in IRIS.

     

    1.8.3 The Center safety office shall record mishaps involving injury or illness to NASA civil service employees on the OSHA 300 Log as required by 29 CFR Part 1904.7.

     

    1.8.4 The Center safety office shall ensure that the information recorded in IRIS is updated as new information becomes available and, at a minimum, verify information is up to date once every 30 days until the investigation is complete.

     

    1.9 Collateral Investigations

     

    1.9.1 The NASA investigating authority performing the safety investigation per this NPR shall have primacy over other Agency collateral investigations, with the exception of OIG criminal investigations.

     

    1.9.2 The investigating authority shall not distribute witness statements, notes, or transcripts of witness testimony taken during interviews, or medical records to the collateral investigation board, OIG, or any other Agency, unless ordered in a court of law.

     

    1.9.3 The investigating authority may provide (at their discretion) the collateral investigation board with access to factual data, physical evidence (with the exception of privileged witness statements, notes and transcripts of privileged testimony, and medical records), analysis, and any other information that will be contained within the mishap investigation report authorized for public release.

     

    1.10 Investigations by Outside Authorities

     

    1.10.1 If the NASA appointing official accepts an investigation by other authorities that is independent and adequately addresses proximate cause(s), root cause(s), and contributing factor(s), the appointing official is not required to conduct a separate NASA investigation.

     

    1.10.2 Examples of situations where investigations by other parties may be accepted include the following:

     

    a. Traffic mishaps involving NASA employees in the course of their duty when investigated by local authorities (i.e., sheriff, state police, coroners) having jurisdiction.

     

    b. An injury or fatality where there is substantial reason to believe the mishap or close call is the result of a criminal or terrorist act to NASA employees and is investigated by local or Federal law enforcement authorities such as the Federal Bureau of Investigation; the Bureau of Alcohol, Tobacco, Firearms, and Explosives; the Department of State; the Drug Enforcement Agency; the Department of Homeland Security; or the OIG.

     

    c. An injury or fatality as a result of a commercial transportation mishap involving NASA personnel on official business that is investigated by authorities having jurisdiction, such as the Federal Aviation Administration and the NTSB.

     

    1.10.3 Contractor and Grantee Mishaps. In those cases that are not NASA mishaps (i.e., solely involve a contractor or grantee mishap or close call at an offsite location, arising out of work performed under a NASA contract and the contractor/grantee is required to investigate pursuant to NFS 1852.223-70), the NASA appointing official is not required to appoint a separate NASA investigating authority unless the contractor's/grantee's mishap report indicates that a NASA policy or procedure was a causal factor or contributing factor and a NASA change is warranted.


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