NASA Procedures and Guidelines
This Document is Obsolete and Is No Longer Used. Check the NODIS Library to access the current version: http://nodis3.gsfc.nasa.gov

NPR 8621.1B
Effective Date: May 23, 2006
Cancellation Date: June 21, 2019
Responsible Office: GA

Table Of Contents

Change History

Preface

P.1 Purpose
P.2 Applicability
P.3 Authority
P.4 References
P.5 Measurement/Verification
P.5 Cancellation

Chapter 1. General Information

1.1 Objectives of NASA Mishap and Close Call Investigations
1.2 Description of NASA Mishaps and Close Calls
1.3 Determining the Classification Level and Type of Investigation to be Conducted
1.4 Roles and Responsibilities
1.5 Notification and Reporting Requirements
1.6 Additional Notification and Reporting Requirements for Aircraft Investigations
1.7 Investigation Product for each Classification Level/Type of Investigation
1.8 Recording Requirements
1.9 Collateral Investigations
1.10 Investigations by Outside Authorities

Chapter 2. Readiness to Conduct Investigations

2.1 Headquarters Operations and Center Mishap Preparedness and Contingency Plan
2.2 Program and Project Mishap Preparedness and Contingency Plans
2.3 Mishap Preparedness and Contingency Plan Practice
2.4 Contingency Plan Web Site
2.5 Contract Clauses
2.6 Training
2.7 Tools

Chapter 3. Initial Response to a Mishap or Close Call

3.1 Safe the Mishap Site and Initiate Mishap Preparedness and Contingency Plan(s)
3.2 Notify Headquarters Office of Safety and Mission Assurance within 1 Hour of Type A Mishap, Type B Mishap, High-Visibility Mishap, or High-Visibility Close Call
3.3 Deploy IRT
3.4 Notify Personnel and the Public of Potential Hazards
3.5 Secure the Site and Preserve Evidence
3.6 Impound Data
3.7 Initiate Drug Testing
3.8 Collect Witness Statements
3.9 Coordinate Release of Information
3.10 Notify OSHA
3.11 Record the Mishap

Chapter 4. Select the Investigating Authority and Support

4.1 Determine the Appointing Official for Mishap and Close Call Investigation
4.2 Select the Members of the Investigating Authority (MIB, MIT, or MI)
4.3 Select the Ex Officio
4.4 Select Investigating Authority's Advisors
4.5 Select Investigating Authority's Consultants
4.6 Provide Support to Investigating Authority
4.7 Contents of the Appointment Letter or Appointment Orders

Chapter 5. Mishap Investigation Process

5.1 Overview of the Mishap Investigation Process
5.2 Prepare for the Investigation
5.3 Verify that the Site is Safe and Secured and Ensure Evidence is Preserved/Impounded
5.4 Gather Physical Evidence and Facts
5.5 Interview Witnesses
5.6 Review and Analyze Data
5.7 Draw Conclusions and Document Findings
5.8 Generate Recommendations
5.9 When and How to Turn Over for Criminal Investigation
5.10 Release the Mishap Site and Restore Site Operations

Chapter 6. Mishap Report

6.1 Develop the Mishap Report
6.2 Release Investigating Authority
6.3 Review, Endorse, and Approve Mishap Report
6.4 Authorize Mishap Report for Public Release
6.5 Distribute Mishap Report

Chapter 7. Post-Investigation Activities

7.1 Develop CAP
7.2 CAP Contents
7.3 Review and Approve CAP
7.4 Implement CAP
7.5 Monitor and Closeout CAP
7.6 Develop, Disposition, Submit, and Approve Lessons Learned
7.7 Conclude Mishap Activities
7.8 Record and Retain Evidence

Appendices

Appendix A. Terms and Definitions
Appendix B. Acronyms
Appendix C. Mishap Investigation Notional Time Line

List of Figures

Figure 1. Mishap Classification Levels and Type of Investigation to be Conducted
Figure 2. Mishap Organizational Responsibilities Matrix
Figure 3. NTSB Reportable Events (Per 49 CFR Part 830)
Figure 4. Information Required for All Agency Aircraft Mishaps and Close Calls
Figure 5. Classification Level/Investigation Type with Corresponding Appointing Official, Endorsing Officials, and Required Products in the Mishap Report
Figure 6. Statement that Shall Be Read to Witness at the Start of His/Her Formal Interview
Figure 7. Typical Steps in the Mishap Investigation

Change History

NPR 8621.1B, NASA Procedural Requirements for Mishap and Close Call Reporting, Investigating, and Recordkeeping

Preface

P.1 Purpose

a. The purpose of this NASA Procedural Requirements (NPR) is to provide requirements to report, investigate, and document mishaps, close calls, and previously unidentified serious workplace hazards to prevent recurrence of similar accidents. This NPR does not apply to investigative procedures concerning civil, criminal, or administrative culpability or legal liability. Furthermore, the safety investigation outlined in this NPR shall not be used to direct or justify disciplinary action for mishaps or close calls (Requirement 44011).

b. This NPR provides requirements that specify how to respond to any mishap or close call from discovery through corrective action and closure. It contains requirements for classifying mishaps, establishing investigation authorities, and performing investigations. It formalizes notification, analysis, and reporting obligations; describes roles and responsibilities; provides instruction on release of information to the public; and specifies the relationship and interaction with the Occupational Safety and Health Administration (OSHA), the National Transportation Safety Board (NTSB), and other government agencies.

P.2 Applicability

a. This NPR is applicable to NASA Headquarters and Centers, including Component Facilities; the Jet Propulsion Laboratory, a Federally Funded Research and Development Center, and other NASA contractors and grantees as specified in their contracts or grants; and to other organizations (i.e., commercial partners, other Federal agencies, international parties, and tenants on Centers) as specified and described in written operating agreements. This NPR is applicable to mishaps and close calls for NASA-funded activities at any government, contractor, subcontractor, or grantee site.

b. The concept of word usage and intended meaning is as follows: "Shall" has been used only when application of a procedure is a mandatory requirement. "Should" has been used only when application of a procedure is recommended.

P.3 Authority

a. The National Aeronautics and Space Act, 51 U.S.C. §20113(a), as amended.

b. Inspector General Act of 1978, 5 U.S.C. App. 3, as amended.

c. Occupational Safety and Health Act of 1970, Section 19, as amended, 29 U.S.C. §668.

d. Recording and Reporting Occupational Injuries and Illnesses, 29 C.F.R. pt. 1904.

e. Basic Program Elements for Federal Employees, Occupational Safety and Health Programs and Related Matters, 29 C.F.R. pt. 1960.

f. Notification and Reporting of Aircraft Accident or Incidents and Overdue Aircraft, and Preservation of Aircraft Wreckage, Mail, Cargo, and Records, 49 C.F.R. pt. 830.

g. NPD 8700.1, NASA Policy for Safety and Mission Success.

P.4 Applicable Documents

a. U.S.C. 101, Definitions.

b. NPD 9800.1, NASA Office of Inspector General Programs.

c. NPR 1441.1, NASA Records Retention Schedules (Schedule 1).

d. NPR 1600.1, NASA Security Program Procedural Requirements.

e. NPR 7120.5, NASA Space Flight Program and Project Management Requirements.

f. NPR 3792.1, Plan for a Drug-Free Workplace.

g. NASA Federal Acquisition Regulation (FAR) Supplement (NFS) Part 1807, Acquisition Planning.

h. NFS Part 1852.223-70, Safety and Health.

i. Publication L. 109-155, Sec. 821, NASA Authorization Act of 2005; Human Space Flight Independent Investigation Commission.

j. Incident Reporting Information System (IRIS).

k. NASA Lessons Learned Information System (LLIS) (http://llis.gsfc.nasa.gov/).

P.5 Measurement/Verification

Compliance with the requirements contained in this NPR will be verified through processes contained in NPR 8705.6, Safety and Mission Assurance Audits, Reviews, and Assessments.

P.6 Cancellation

/s/
Bryan O'Connor
Chief, Safety and Mission Assurance

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 before the scheduled completion of the planned primary mission.

1.2.1.5 Destruction of, or damage to, NASA property.

1.2.2 The situations in 1.2.2.1-1.2.2.6 are not considered a NASA mishap or close call.

1.2.2.1 Illness or fatalities that are due to natural causes or are unrelated to the work environment when the disease, not the injury, is the proximate cause of the lost time, such as diabetes and its resultant complications (e.g., loss of vision).

1.2.2.2 Attempted or consummated suicide or intentionally self-inflicted injuries.

1.2.2.3 Injuries or fatalities resulting from altercations, attack, assault (unless incurred in the performance of official duties: for example, criminal investigators), or homicide.

Note: Incidents involving personnel injured as a result of violence in the work environment will be reported to the U.S. Department of Labor in accordance with 29 CFR 1904.5.

1.2.2.4 Destruction of, or damage to, any property (public, private, or Government) on a Center or involving NASA property on the ground outside the Center's gates, as a direct result of:

a. Weather conditions such as, but not limited to, hurricane, lightning, tornado, high winds, dust storm, tidal wave, tsunami, water spout, or ice/snow loads;

b. Natural phenomenon such as, but not limited to, a flood, landslide, earthquake, meteoroid landing, or volcanic eruption;

c. Wild fire; or

d. Vandalism, riots, civil disorders, or felonious acts such as arson or stealing.

Note 1: In these cases, the weather, natural phenomenon, wild fire, vandalism, riot, civil disorder, or felonious act is the proximate cause for the mishap to be exempt from the mishap classification. For example, if the weather was an intermediate cause or a contributing factor to a mishap, this exemption to "mishap classification" would not apply. A bird strike to an airplane is not exempt.

Note 2: Damage to NASA aircraft, vehicles, or any other property which occurs after an aircraft or vehicle has been stolen is not reportable as an accident. Damage to NASA aircraft, vehicles, or any other property that occurs when an individual misappropriates an aircraft or vehicle not authorized to be flown or driven by the individual will not be reported as an accident.

e. Intentional, controlled jettison or release, during flight, of canopies, cargo, doors, drag chutes, hoist cable, hatches, life rafts, auxiliary fuel tanks, missiles, drones, rockets, and externally carried equipment not essential to flight, when there is no injury, illness, or reportable collateral damage and, in the case of missiles or drones, when the reason for jettison is not malfunction.

f. Accidents occurring during the transportation of NASA material by commercial carriers, when NASA and/or NASA contractors had no roles or responsibilities for packing, securing, or transporting the items.

Note: If NASA or a NASA contractor was responsible for the safety of the transport or performed any activities related to securing and/or transporting the hardware, the incident would be evaluated to determine if it was a NASA mishap. In the past, NASA contractors have failed to adequately secure a load, which resulted in a transportation accident. This would still be considered a NASA mishap.

g. Accidents involving civil aircraft owned by civil operators and accomplishing contract air missions for NASA, where there is no NASA property damage or civil servant injury.

h. NASA equipment that resides off-site that is leased, on bailment, or loaned to contractors, commercial airlines, other Government agencies, or foreign governments when the lessee has assumed risk of damage or loss.

1.2.2.5 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 of the component 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 a fatality, injury, or damage to another component or the facility.)

1.2.2.6 Test-induced damage is not considered a mishap provided that all of the following are true:

Note 1: NASA conducts tests to better understand and mitigate complex design, manufacturing, or operational issues. The objective of testing is to provide NASA with confidence that the system meets its technical and programmatic requirements and can successfully and safely perform its mission in the operational environment. Some tests, by their nature, are designed and intended to result in hardware damage: for example, a structural test-to-failure. Other tests are aggressive in nature, and test-incurred damage often occurs and the knowledge gained is used to improve designs. These instances of test damage would be a reportable NASA mishap if the failure/damage manifested was associated with procedural errors or with a noncompliance to design or construction requirements OR if it caused harm to personnel or to uninvolved equipment, facilities, or property.

Note 2: For the purposes of mishap determination, development tests are not "missions" nor are development test objectives "mission objectives" unless specifically defined as such in the program, project, or mission premishap plan.

a. The test-induced damage did not result in:

(1) Injury, illness, or fatality.

(2) Damage to public property, other Government agency property, or private property (e.g., a personnel-owned vehicle), regardless of location of that property.

Note: Where public, government, or private property is located within a military test range, and the risk to such property is formally approved/accepted by the range authority as part of the test approval process, NASA may support and accept the mishap classification, reporting, and investigation completed by the outside authority (the Federal agency authorized to investigate the military range) as described in paragraph 1.10 of this document.

(3) Hazardous hardware debris leaving the test cell, test chamber, protected facility, and/or test range.

b. The facility and test equipment functioned properly (except when functions of the facility and/or test equipment themselves are being tested and part of approved test objectives).

c. The damage is limited to test article(s) or test facility(ies), and the risk of damage was formally documented and accepted via signature before the test. The type or general category (i.e., water damage, structural failure, thermal overload) of test-induced damage was documented as a designed/intended or potential outcome of the test, and the risk (including related uncertainties) of the test-induced damage was formally accepted by appropriate authority(ies). Depending on the test, the appropriate authority may be the owner(s) of the damaged property and/or the person(s) responsible for funding replacement of damaged equipment (e.g., owner of the test article, test support equipment, test cell, chamber, pad, protected facility, and/or range, project, or program manager).

Note 1: The signed document describing the risk of potential test-induced damage outcomes includes the test team's best understanding of the uncertainties in environments, test limits, and/or system performance.

Note 2: Examples of test-induced damage incidents that may be accepted "prior to testing" in a test plan or related document include:

1. Structural damage due to planned structural tests-to-yield when performance between yield and ultimate failure is uncertain.

2. Unplanned but acceptable limited erosion of a flame trench during launch or engine firing.

3. Thermal damage to brakes and tires during a maximum braking test.

4. Thermal, blast, or erosion damage to cables and other normally exposed equipment on a launch pad or in an explosive chamber.

5. Excessive splashdown structural damage to a recoverable booster when new parachute performance is uncertain.

6. Loss of test hardware due to known, accepted deficiencies in the test and/or test support system (i.e., planned use of off-the-shelf low-reliability sounding rockets for low-cost suborbital tests).

7. Crash damage to a model airplane due to known and accepted controller handling quality limitations.

8. Damage resulting from one or more of the following:

(a) Acknowledged limitations in pretest analysis/models and/or uncertainties in analysis/model/environmental predictions.

(b) Planned test operations in known and approved hazardous environmental conditions. Purposefully testing in an organizational environment where NASA, by formal choice, does not control hazards (i.e., Space Act or international agreements where NASA cedes design and/or operational risk management to the partner).

Note 3: Examples of test-related damage that would normally not be "accepted risks" and, therefore, would be candidates for mishap categorization include:

1. Damage due to human error in test setup or conduct when relevant human performance is not part of the test objectives.

2. Damage due to deficient or otherwise less than standard test planning or test design.

3. Damage to the test article due to test facility malfunction during a test.

4. Damage due to test facility software malfunction when relevant software performance is not part of the test objectives.

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

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 or close call (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 44074).

1.3.2 When the Administrator, Associate Administrator (AA), Mission Directorate Associate Administrator (MDAA), Chief Office of Safety and Mission Assurance (Chief/OSMA), the Designated Agency Safety and Health Official (DASHO), Center Director (CD), or the Executive Director, Office of Headquarters Operations (ED/OHO), believes that the mishap or close call is a high-visibility event, he/she may elevate the mishap classification level of investigation to the classification he/she deems appropriate and request the appropriate appointing official to form a Mishap Investigation Board (MIB).

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

1.3.3.1 The responsible manager, with review and concurrence by the Center safety office, shall calculate the direct cost of a mishap or close call by adding all the actual costs (or the estimate of the cost) (the greater value of actual or fair market value) of damaged property, destroyed property, or mission failure; i.e., 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 (Requirement 44077).

Note 1: The initial estimate of the direct cost is calculated in the first 24 hours (paragraph 1.5.5), because the appointing official uses this estimate to determine the classification of the incident and the resources to allocate to the investigation. The final direct cost is calculated as the damage assessments are completed and is incorporated into the mishap investigation report (paragraph 6.1.6). The final mishap classification level could change based on the final estimate of the direct cost.

Note 2: Replacement cost to purchase commercially available part or manufacture custom part as needed to be an equivalent replacement.

1.3.3.2 Even 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 or close call shall include the actual costs of replacement parts as if these were purchased new, plus labor calculated as if the salvage/excess parts were unavailable (Requirement 44078).

1.3.3.3 In cases where insurance compensation, contractor compensation, or other compensation is available or provided, the direct cost of the mishap or close call shall include the direct cost (or estimate of the cost) as if this compensation were not available or provided (Requirement 44079).

1.3.3.4 The cost of the safety mishap investigation shall not be included in the direct cost (Requirement 44080).

1.3.3.5 The responsible program manager (or designee), in coordination with the Chief Financial Officer (or designee), shall calculate the cost of a mission failure by determining the cost of the "unique" mission from Mission Approval (Key Decision Point C) through project closeout, including consumables (e.g., fuel), launch costs, and dedicated institutional support costs such as Deep Space Network, NASA Engineering and Safety Center, Independent Technical Authority, or others.

Note 1: Example of Mission Failure
The Space Shuttle loses a main engine on ascent and must perform a Return to Launch Site (RTLS) launch abort. The preapproved minimum mission success criteria are obviously unmet. The cost of this mission failure would be the cost of the Space Shuttle processing and operations (labor and consumables) dedicated to this mission and any payload processing and integration that would have to be redone for reflight. If, after the abort, the Agency decides not to refly, then the cost of the mission failure would include the entire payload cost accrued since its approval (Key Decision Point C or equivalent). Note 2: Examples of Incidents That Would Not Be Considered a Mission Failure:
The Mars Exploration Rover Spirit fails next week (long after it has met its minimum success criteria (minimum mission objectives)). This would not be classified as a mission failure, so no cost would be assigned. The program manager may choose to investigate this failure, but there would be no cost assigned.

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

1.4 Roles and Responsibilities

1.4.1 Administrator. The Administrator:

a. May elect to be the appointing official for Type A mishaps or delegate to the AA. (If the Administrator elects not to be the appointing official, the MDAA, CD, or another designee will serve as the appointing official.) (Requirement 44083).

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 44084).

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

1.4.2 Chief/OSMA. The Chief/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 44087).

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 44088).

c. Provide a qualified NASA person to support NTSB investigations of NASA aircraft mishaps (Requirement 44089).

d. Archive NASA Headquarters-approved NASA mishap investigation board reports and related documents per NPR 1441.1 (Requirement 44090).

1.4.3 Inspector General. The Inspector General shall investigate criminal activity associated with mishaps and close calls (Requirement 44091).

1.4.4 AA. The AA shall:

a. Serve as the appointing official for Type A mishaps if designated by the Administrator (Requirement 44093).

b. Obtain concurrence from the Chief/OSMA and the Chief Engineer on the MIB membership of mishaps in which he/she is the appointing official (Requirement 44094).

c. Serve as an endorsing official for all mishaps in which he/she is the appointing official (Requirement 44095).

1.4.5 MDAA. The MDAA shall:

a. Implement the mishap and close call reporting, investigating, and recordkeeping requirements for their assigned Mission Directorates for mishaps and close calls that occur outside the Center's gates, during in-space flight, or at a program/project contractor site that is not managed by a Center (Requirement 44097).

b. Approve via signature all his/her program and project (as defined in NPR 7120.5) Program/Project Mishap Preparedness and Contingency Plans. (These plans will be developed by the cognizant Center safety offices, and will include procedures to notify, report, investigate, and record mishaps and close calls that involve Mission Directorate programs/projects/activities whether onsite or offsite, and whether on the ground or in flight.) (Requirement 44098).

Note: All mishaps that occur at a Center are investigated per the Center's Mishap Preparedness and Contingency Plan. The program's plan supports the Center plan by providing additional information such as, but not limited to, hazardous materials, partner agreements, and program contact lists. It also serves as a stand-alone plan for mishaps and close calls that occur outside the Center's gates, during in-space flight, or at a program/project contractor site.

c. Determine the mishap classification level (or assign a designee to determine the classification level) for all mishaps for which he/she has reporting responsibility and obtain concurrence on this classification level from the Chief/OSMA for Type A and B mishaps, high-visibility mishaps, and high-visibility close calls ((Requirement 44100).

Note: Aircraft Operations are managed by a program-independent flight operations office; therefore, the Center Director serves as the appointing official for Type A mishaps, Type B mishaps, high-visibility mishaps, and high-visibility close calls involving aircraft managed by his/her Center.

d. Serve as the appointing official for Type A mishaps, Type B mishaps, high-visibility mishaps, and high-visibility close calls that involve Mission Directorate managed programs/projects/activities that occur during space flight or occur outside the Center's gates at MDAA program/project sites (excludes off-site Center support contractor locations) (Requirement 44102).

Aircraft Operations are managed by a program-independent flight operations office; therefore, the Center Director serves as the appointing official for mishaps and close calls involving aircraft managed by his/her Center.

e. Serve as the appointing official (or designate the responsibility in the Program/Project Mishap Preparedness and Contingency Plan) for Type C mishaps, Type D mishaps, and close calls that involve Mission Directorate managed programs/project/activities that occur during space flight or occur outside the Center's gates, during at MDAA program/project sites (excludes off-site Center support contractor locations) (Requirement 44104).

f. Provide funding and support for investigations within their programs and involving their hardware, facilities, or enabling activities (Requirement 44105).

g. Ensure that agreements for joint programs with international partners and other Federal agencies incorporate elements of this NPR to ensure that joint mishap investigating and reporting complies with NASA requirements (Requirement 44106).

1.4.6 Assistant Administrator, Office of Public Affairs (AA/OPA).

a. The AA/OPA shall establish guidelines for the public release of mishap reports and related information (Requirement 44108).

b. With the assistance of the Center safety office, Interim Response Team (IRT), investigating authority, and CD or ED/OHO, 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 44109).

c. For Type A mishaps, Type B mishaps, high-visibility mishaps, and high-visibility close calls, the AA/OPA (or designee) shall appoint a Headquarters public affairs advisor (Requirement 31098). (For Type B mishaps the AA/OPA may delegate authority to appoint a public affairs advisor to the Center Public Affairs Office [PAO].) (Requirement 44110).

1.4.7 CD and ED/OHO. The CD and the ED/OHO shall:

a. Develop Center and Program Mishap Preparedness and Contingency Plans to support this NPR (this includes procedures to notify, report, investigate, and record mishaps and close calls that involve programs, projects, and activities that fall under their responsibility) (Requirement 44144).

b. Implement the mishap reporting, investigating, and recordkeeping requirements for all projects, programs, and activities that fall under their SMA responsibility (Requirement 44115).

c. Provide funding and support for investigations at their Centers, within their projects and programs, and involving their hardware, facilities, or enabling activities (Requirement 44116).

d. Determine the mishap classification level (or assign a designee to determine the classification level) for all mishaps for which the Center has reporting responsibility and obtain concurrence on this classification level from the Chief/OSMA for Type A and B mishaps, high-visibility mishaps, and high-visibility close calls (Requirement 44117).

e. Serve as the appointing official for Type A mishaps, Type B mishaps, high-visibility mishaps, and high-visibility close calls that occur at his/her Center, at off-site Center support contractor locations, or at off-site contractor locations that are managed by the Center and are not part of any MDAA program/project activity (Requirement 44118).

Note: Aircraft Operations are managed by a program-independent flight operations office; therefore, the Center Director serves as the appointing official for mishaps and close calls involving aircraft managed by his/her Center.

f. Serve as the appointing official (or designate the responsibility in the Center Mishap Preparedness and Contingency Plan) for Type C mishaps, Type D mishaps, and close calls that occur at his/her Center, at off-site Center support contractor locations, or at off-site contractor locations that are managed by the Center and are not part of any MDAA program/project activity (Requirement 44120).

g. In the event that there is a mishap involving injury of a human research subject at a NASA Center, request the Chief Health and Medical Officer (CHMO) concurrence on the investigating authority's membership (Requirement 44121).

h. Personally report, by telephone or e-mail, to the Administrator within 24 hours of learning the instance of any NASA Type A mishap,or NASA Type B mishap, and personally report (or Deputy to report), by telephone or e-mail, to the Associate Administrator within 24 hours of learning the instance of any NASA Type C mishap that involves a lost-time injury or illness (Requirement 44122).

i. Personally report, by telephone or e-mail, to the Administrator within 24 hours of any nonoccupational fatality, such as sudden cardiac arrest of a NASA civil service employee or a resident contractor that occurred on site (a resident contractor is a NASA contractor whose primary place of business is on or near a NASA Center or NASA-owned facility) (Requirement 44123).

j. Personally report, by telephone or e-mail, to the Administrator when it becomes known that there is any off-the-job fatality or serious injury/illness of a NASA civil service employee or resident contractor (Requirement 44124).

k. Ensure that local procedures for dealing with the needs of the NASA workforce (civil service employees and contractor employees) when they are experiencing a crisis situation (e.g., serious injury, illness, or fatality of workforce member or family member) are:

(1) Reviewed annually (Requirement 44126).

(2) Include a process for immediately notifying the next of kin for mishaps and on site nonoccupational medical events resulting in fatality or serious injury (Requirement 44127).

(3) Provide information to the person or family (when the person is unable to receive such information due to the injury or illness) concerning benefits, such as extended sick-leave and disability (Requirement 44128).

l. Ensure that the NASA civil service employees designated to communicate with the family of an injured, ill, or deceased individual have received training in NASA policy concerning benefits and crisis intervention (Requirement 44129).

m. Initiate the use of the NASA Family Assistance Fund (NFAF), upon the NASA civil service employee family's agreement or request (Requirement 44130).

Note: The NFAF, in cooperation with the Federal Employees Education and Assistance Fund (FEEA), is available to help meet the unforeseen medical, financial, and educational needs of NASA civil service employees. NFAF and FEEA do not provide assistance to contractors. Upon request from a NASA civil service employee, NASA Human Resources, Personnel Division, will contact the Chair of the NFAF and FEEA's Washington Representative, to request assistance. FEEA can assist with immediate financial needs, such as funeral expenses, medical expenses, and short-term financial hardships.

n. Obtain concurrence from the Chief/OSMA and the Chief Engineer on the MIB membership of Type A, Type B, high-visibility mishaps, and high-visibility close calls in which he/she is the appointing official (Requirement 44132).

o. Provide administrative and logistical support for the investigating authority working on the Center and distribute the authorized mishap report per this NPR (Requirement 44133).

p. 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 44134).

q. Serve as an endorsing official for mishaps and close calls in which he/she is the appointing official (Requirement 44135).

1.4.7.1 The ED/OHO shall provide funding and support for investigations of mishaps that occur at NASA Headquarters (Requirement 67138).

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

a. Concur on the Program/Project Mishap Preparedness and Contingency Plan (Requirement 44137).

b. In the event of a mishap or close call at the Center, activate the Program Mishap Preparedness and Contingency Plan (Requirement 44138).

c. Provide funding and support for investigations within their program jurisdiction or involving their hardware and facilities (Requirement 44139).

d. Assist the investigating authority as requested (Requirement 44140).

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 44141).

1.4.9 Responsible Organization. The responsible organization shall:

a. Assist the investigating authority as requested (Requirement 44143).

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 44144).

1.4.10 Appointing Official. The appointing official shall:

a. Use this NPR to determine the type of investigating authority (i.e., Mishap Investigation Board [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 44146).

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 44147).

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 44148).

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, and the advisors. (For Type C mishaps, Type D mishaps, and close calls, the appointment orders can be less formal and communicated via a Center process.) (Requirement 44149)

e. Serve as an endorsing official for mishaps and close calls in which he/she is the appointing official (Requirement 44151).

f. Assign the responsible organization(s)/program(s)/project(s) to develop the CAP, implement the CAP, and generate the lessons learned (Requirement 44152).

g. Ensure that the mishap investigation process for the assigned mishap or close call is properly completed (Requirement 44153).

h. Verify that the mishap report is reviewed, endorsed, and authorized for public release (Requirement 44154).

i. Ensure that the CAP is developed and implemented (Requirement 44155).

j. Ensure that the lessons learned are developed, reviewed, and authorized for public release (Requirement 44156).

k. Release the investigating authority from duty (Requirement 44157).

l. Generate the CAP closure statement and the mishap activities completion statement (Requirement 44158).

m. Assist the investigating authority as requested (Requirement 44159).

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

(1) Initiate a NASA mishap investigation per this NPR (Requirement 44161).

(2) Request that a NASA representative be a party to the NTSB's investigation (Requirement 44162).

Note: It is imperative that the appointing official communicate the time commitment and expectations with the supervisor of individuals selected to serve on mishap investigations and obtain the supervisor's agreement prior to appointing individuals to an investigating authority.

1.4.11 Endorsing Official.

a. 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 44164).

b. This endorsement and any comments shall be attached to the mishap report and become part of the permanent record (Requirement 44165).

1.4.12 Ex Officio. The ex officio shall:

a. Serve as the authorized representative of the Chief/OSMA (Requirement 44167).

b. Be a nonvoting participant in all investigation deliberations (Requirement 44168).

c. Participate in all investigation proceedings as he/she deems appropriate (Requirement 44169).

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 44170).

Note: When available, an OSMA's Mishap Investigation Support Office mishap investigation specialist is the preferred choice as ex officio for Type A and Type B mishaps and high-visibility mishaps and close calls investigations.

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 44171).

f. Sign the final mishap report demonstrating his/her belief that paragraphs 1.4.12.d-1.4.12.e, and paragraphs 1.7.1.a-1.7.1.l of this NPR have been satisfied or attach a signed written description of the report's deficiencies (Requirement 44172).

g. For Type A mishaps, Type B mishaps, high-visibility mishaps, and high-visibility close calls, provide the Chief/OSMA interim briefings on the status of the investigation, upon his/her request (Requirement 44173).

1.4.13 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; interview witnesses; reconstruct the mishap or close call; identify facts; identify proximate cause(s) and root cause(s); generate recommendation(s); and complete the mishap report (Requirement 44175).

b. Have the authority to impound data, records, equipment, and facilities and collect/salvage data and debris (Requirement 44176).

c. For mishaps at contractor or subcontractor sites, work through the contracting officer with guidance from the legal advisor to obtain and impound data (Requirement 44177).

Note: For mishaps outside the Center's gates, NASA has the authority to impound NASA property, however, the ability to impound or collect other data, records, and equipment is determined by the local and Federal laws, Agency agreements, and contracts.

d. Release impounded data, records, equipment, facilities, and the mishap site when they are no longer needed by the investigating authority (Requirement 44179).

Note: If repairs or modifications need to be made prior to returning equipment or facilities to use, the release of impounded items should include a letter stating what action(s) is (are) needed.

e. Define the roles and/or areas of investigative responsibility for each group or subgroup on the MIB or MIT, as needed (Requirement 44181).

f. Coordinate with the investigating authority's legal advisor, Headquarters or Center public affairs advisor, and import/export control advisor throughout the investigation (Requirement 44182).

g. Report only to the appointing official (or designee) during the investigation (Requirement 44183).

Note: The intent of this requirement is to provide the Chair of the Investigating Authority with only one supervisor during the investigation, thereby preventing numerous NASA requests for data and status. The report to the appointing official may include information such as a status, facts, preliminary findings (if the Chair desires), and recommendations which need immediate implementation.

h. Refer allegations and evidence of criminal activity that are identified in the course of an investigation to the Office of Inspector General (Requirement 44185). Privileged witness statements will be protected to the extent provided by law.

1.4.14 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 44187).

1.4.15 Investigating Authority's Advisors. The advisors shall:

a. Attend meetings as needed, travel with the investigating authority as requested, and have access to all investigative material with the exception of witness statements and testimony (Requirement 44189).

Note: The legal advisor may review witness statements and testimony in order to provide adequate legal guidance.

b. Provide advice to the investigating authority (Requirement 44191).

c. Sign the mishap report stating that he/she has reviewed the mishap report and that it meets NASA policies and procedures in his/her functional area. (Requirement 44192).

1.4.16 Legal Advisor. The legal advisor shall:

a. Develop nondisclosure agreements if the investigating authority uses a contractor as administrative support (Requirement 44194).

b. Develop nondisclosure agreements if the investigating authority uses a contractor to analyze interview data or participate in interviews (Requirement 44195).

c. Provide legal advice and counsel as requested by the board chair (Requirement 44196).

d. Attend interviews, if the interviewee is accompanied by a lawyer during the interview process (Requirement 44197).

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

1.4.17.1 The chairperson may exclude advisors (with the exception of the legal advisor) from participating in deliberations that discuss privileged witness testimony (Requirement 44199).

Note: The legal advisor may review witness statements and testimony in order to provide adequate legal guidance.

1.4.18 Investigating Authority's Consultants. Per their contract, consultants shall:

a. Provide advice to the investigating authority (Requirement 44202).

b. Perform analysis (Requirement 44203).

c. Assist in formulating conclusions, as requested (Requirement 44204).

1.4.19 The consultants shall not:

a. Participate in deliberations (vote on findings) (Requirement 44206).

b. Sign the mishap report (Requirement 44207).

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 the General Counsel or Center Chief Counsel (Requirement 44208).

Note: Contractors specializing in witness interview techniques or technical expertise may be hired by the MIB, if the following are true: the contractor hired to support the MIB:

a. is not affiliated with the mishap, the contractors, or responsible organizations involved in the mishap;

b. is specifically tasked by contract to support the interview process or analyze interviews;

c. has signed the nondisclosure agreement prior to their participation or support; and

d. NASA does not have a sufficient number of Federal employees or expertise on the board to perform the task.

1.4.20 If the Chair of the Investigating Authority chooses to use a person that is not a Federal employee as administrative support, that person shall sign a nondisclosure agreement prior to having access to any mishap data or International Traffic Arms Regulations (ITAR), Export Administration Regulations (EAR), proprietary, or privileged information (Requirement 44214).

Note: An administrative support person may support the mishap board. This support may include access to privileged interview statements as long as the person is a Federal employee or the person has signed the appropriate nondisclosure agreement prior to having access to any mishap data or information.

1.4.21 Interim Response Team (IRT). The IRT shall:

a. Notify the Center PAO about casualties, damages, and any potential hazards to the public, and notify legal advisors (as appropriate) (Requirement 44217).

b. Assist the incident commander, as requested (Requirement 44218).

c. Preserve evidence, document the scene, identify witnesses, and collect debris (Requirement 44219).

d. Only Federal employees on the IRT shall support the Center safety office in impounding data and collecting witness statements (written statements when possible) (Requirement 44220).

e. For mishaps at contractor or subcontractor sites, the IRT shall work through the contracting officer, with the guidance from the legal advisor, to obtain and impound data (Requirement 44221).

Note: For mishaps outside the Center's gates, NASA has the authority to impound NASA property, however, the ability to impound or collect other data, records, and equipment is determined by the local and Federal laws, Agency agreements, and contracts.

f. Advise the supervisor if drug testing should be requested per the NPR 3792.1, Plan for a Drug-Free Workplace (Requirement 44223).

Note: Per NPR 3792.1 the supervisor shall 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. This applies to Federal employees only. Drug testing of contractors is dependent upon their contract.

g. Provide all available mishap data and evidence to the investigating authority (Requirement 44225).

h. Support the AA/OPA (or designee), Center safety office, IRT, and CD or ED/OHO in the release of information to the press and media to alert Center personnel and the public of any known hazards and their potential effects, and provide instructions that will mitigate the risk and harm (Requirement 44226).

1.4.22 Incident Commander. The incident commander shall implement the procedures outlined in the Center Mishap Preparedness and Contingency Plan to coordinate rescue activities, mitigate hazards, and safe and secure the mishap site (Requirement 44227).

1.4.23 Center Safety Office. The Center safety office shall:

a. Support the development of the Center Mishap Preparedness and Contingency Plan, Program Mishap Preparedness and Contingency Plan(s), contract clauses, mishap investigation training, and a mishap investigation tool repository (that makes tools readily accessible to investigating authorities) (Requirement 44229).

b. Develop the Program/Project Mishap Preparedness and Contingency Plans for Programs/Projects as defined by NPR 7120.5 and that their Center manages (Requirement 44230). Programs with aircraft in the developmental, qualification, or certification phases of the program shall have a Program Mishap Preparedness and Contingency Plan that is tailored for the particular phase of the program. (Requirement 68379).

c. Ensure that their Center's employees are familiar with the roles and responsibilities as documented within the Center Mishap Preparedness and Contingency Plan and this NPR (Requirement 44231).

d. Implement the Center Mishap Preparedness and Contingency Plan; when applicable, support the program as they initiate the Program Mishap Preparedness and Contingency Plan; and initiate, facilitate, and coordinate all investigation activities per the plan (Requirement 44232).

e. Report the mishap to Headquarters per the reporting requirements defined in this NPR and to OSHA (when applicable) (Requirement 44233).

f. Support the incident commander as he/she safes and secures the mishap site (Requirement 44234).

g. Impound data, records, equipment, and facilities (Requirement 44235).

h. Advise the supervisor that drug testing should be initiated (Requirement 44236).

i. Collect witness statements (written statements preferred) (Requirement 44237).

j. Ensure that mishap and close call information is entered in the Incident Reporting Information System (IRIS) per the requirements outline in this NPR (Requirement 44238).

Note: Close calls involving aircraft may be entered into the NASA Aviation Anomaly Reporting System (NAARS) in lieu of IRIS.

k. Verify the CAP is complete and all elements of the investigation have been completed (Requirement 44240).

l. Retain mishap investigation records per NPR 1441.1 and physical evidence (debris) as necessary (Requirement 44241).

m. 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 44242).

1.4.24 The Office of Protective Services (OPS) shall:

a. Upon request from the appointing official, perform a classification review of the endorsed mishap report to determine if any section of the report (or the whole report) needs to be classified or if it may be authorized for public release (Requirement 44245).

1.4.25 The Center security office shall:

a. Support the Incident Commander, Center safety office, and IRT in securing the mishap site and impounding data, records, equipment, and facilities (Requirement 44247).

1.4.26 Supervisors. Supervisors shall:

a. Notify the Center safety office when a mishap or close call occurs (Requirement 44249).

b. Support the incident commander as he/she secures and safes the mishap site (Requirement 44250).

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 44251).

d. Assist the investigating authority, as requested (Requirement 44252).

e. Complete the initial mishap or close call report in accordance with the Center Mishap Preparedness and Contingency Plan (Requirement 44253).

1.4.27 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, Center security office) 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 44255).

b. Complete witness statements prior to leaving the mishap investigation site, to the extent possible (Requirement 44256).

c. Provide as much information as possible to the investigating authority (Requirement 44257).

1.4.28 Center's Chief of Aircraft Operations. The Chief of Aircraft Operations shall notify the NTSB of a mishap involving aircraft per paragraph 1.6.6 of this NPR and complete NTSB Form 6120 per paragraph 1.6.8 of this NPR and NTSB requirements (Requirement 44258).

1.4.29 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 44260).

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 44261).

c. Coordinate with the contractor and subcontractor sites to assist the investigating authority in gaining contractor site access, impound contractor data, and interview contractor personnel as permitted by the contract (Requirement 44262).

1.4.30 CHMO. The CHMO shall:

a. Serve as the appointing official for a mishap involving a human research subject participating in NASA-funded research at a grantee site, or at another offsite location, and obtain the concurrence from the Chief/OSMA on the investigating authority's membership (Requirement 44264). In these investigations, the investigating authority composition shall include a safety officer that is trained in mishap investigation (Requirement 44265).

Note: If the mishap involving a human research subject occurs at a Center, the Center Director will serve as the appointing official per this NPR. For mishaps involving a human research subject the endorsement and authorization for public release processes will remain the same.

b. Serve as an endorsing official for Type A mishaps, Type B mishaps, high-visibility mishaps, and high-visibility close calls involving an injury or fatality (Requirement 44267).

1.4.31 Mission Support Directorate, Office of Strategic Infrastructure, Aircraft Division (AD). For Type A mishaps, Type B mishaps, high-visibility mishaps, and high-visibility close calls involving aircraft AD shall serve as an endorsing official (Requirement 44268).

1.4.32 Office of the General Counsel. The Office of the 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 44270).

b. Assist the AA/OPA (or designee) in the review of the approved mishap report as it is being prepared for public release (Requirement 44271).

1.4.33 Chief Engineer. The NASA Chief Engineer shall:

a. Concur on MIB membership for Type A mishaps, Type B mishaps, high-visibility mishaps, and high-visibility close calls (Requirement 44273).

b. Serve as an endorsing official for Type A mishaps, Type B mishaps, high-visibility mishaps, and high-visibility close calls (Requirement 44274).

1.4.34 Roles and responsibilities are summarized in Figure 2.

Figure 2. Mishap Organizational Responsibilities Matrix

Note: In Figure 2, AA/OIA is now Executive Director, Office of Headquarters Operations (ED/OHO). AMD is now Aircraft Division.

Key: * = May be primary. Depends on Level of Investigation. P = Primary, S = Support, C = Concurs

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 1.4.27 of this NPR and the Center Mishap Preparedness and Contingency Plan (Requirement 44277).

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 44278).

1.5.3 Notify Office of Safety and Mission Assurance, Safety and Assurance Requirements Division (OSMA/SARD). 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 OSMA/SARD 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 44279).

a. Mishap notification must be acknowledged (verbally, e-mailed, or faxed) to meet the intent of this requirement (Requirement 44281).

b. 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 44282).

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 44280).

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 44283).

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 44284).

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 44285).

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 44286).

1.5.4.4 After notifying OSHA, the Center safety office shall inform OSMA/SARD that an oral report has been provided to OSHA (Requirement 44287).

1.5.5 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 OSMA/SARD 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 44288).

1.5.6 Report Criminal Activity Associated with NASA Mishaps to the Office of Inspector General (OIG) and to either the Office of the General Counsel or Center Chief Counsel.

1.5.6.1 The 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 44290).

1.5.6.2 Any facts related to criminal activity in connection with a mishap shall be referred to the OIG (Requirement 44291). 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 44294).

Note: Effective March 8, 2010, the NTSB has required additional reporting requirements, which are documented in 49 CFR Part 830 and reflected in this NPR.

Figure 3. NTSB Reportable Events (Per 49 CFR Part 830).

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

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, OV-10, and T-34 (Requirement 44295). 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 44297).

1.6.4 The Center safety office shall notify OSMA/SARD and AD of any aircraft mishap or close call as listed in paragraph 1.6.2 and Figure 3 of this NPR (Requirement 44298).

Note: Figure 3 and paragraph 1.6.2 are NTSB reporting requirements. Consequently, this requirement is in addition to reporting all aircraft-related Type A mishaps, Type B mishaps, high-visibility mishaps, and high-visibility close calls to the OSMA/SARD.

1.6.5 The Center safety office shall ensure that for aircraft mishaps and close calls all information listed in Figure 4 of this NPR (with the exception of the pilot's name) is entered in IRIS (Requirement 44300).

Note: Close calls involving aircraft may be entered into the NAARS in lieu of IRIS.

1.6.6 The Center's Chief of Aircraft Operations or his/her designee shall immediately notify the NTSB, in accordance with 49 CFR Part 830, of any aircraft mishap, incident, or close call listed in Figure 3 and paragraph 1.6.2 of this NPR and notify OSMA/SARD and the Office of Strategic Infrastructure, Aircraft Division (OSI/AD) that NTSB notification has been completed (Requirement 44302).

1.6.7 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 44303).

1.6.8 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 44304).

1.6.9 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 Products 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 per paragraph 6.1.9 and 6.1.10 (Requirement).

b Each advisor's signature per paragraph 6.1.11 (Requirement).

c. List of the investigating authority's consultants (Requirement 44310).

d. An executive summary that does not contain privileged or proprietary information, material subject to the Privacy Act, ITAR information, or EAR information (Requirement 44311).

e. 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 44312).

f. Description of the type of data gathered and evaluated during the investigation (Requirement 44313).

g. Narrative description of the facts including what, when, and where (Requirement 44314).

h. Timeline (Requirement 44315).

i. Description of all structured analysis techniques used and how they contributed to determining the findings (Requirement 44316).

j. Event and causal factor tree or similar graphical representation of the mishap (Requirement 44317).

k. 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 44318).

l. Conclusions and recommendations (Requirement 44319).

m. Minority report, if there is one (Requirement 44320).

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

KEY:

1. Occurs when the Administrator, AA, MDAA, CD, Chief/OSMA, or CHMO decides 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 Mission Directorate 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.
7. Onsite human research subjects.

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 (Requirement 44321).

1.7.3 For Type B mishaps, Type C mishaps, Type D mishaps, and close calls involving a single person, where the injury/illness occurred because an individual fell down the stairs, slipped or tripped on the floor or ground, experienced a musculoskeletal disorder (both cumulative trauma or acute) while performing routine office duties, was bitten by an insect, and/or aggravated a preexisting medical condition, the mishap investigation may be performed by one trained mishap investigator without the support from an ex officio.

Rationale: Brown recluse spider bites result in hospitalization. They do not require a full MIB, complex investigation, and/or report.

1.7.4 The CD or ED/OHO 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 (Requirement 44324).

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 (Requirement 44326).

Note: Close calls involving aircraft may be entered into the NAARS in lieu of IRIS.

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 (Requirement 44328).

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 (Requirement 44329).

1.8.4 The Center safety office shall ensure that the information recorded in IRIS is updated as specified in paragraph 6.5 (Requirement 44330).

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 (Requirement 44332).

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 or any other Agency, unless ordered in a court of law (Requirement 44333).

1.9.3 In an unusual case, the MIB chair shall release privileged witness testimony and related material to the OIG upon receipt of a written request that is signed by the Inspector General or Deputy Inspector General, addressed to the NASA Administrator or Deputy Administrator, and forwarded to the MIB chair from the Administrator's office (Requirement 44334).

Note: The OIG respects and, as a general rule, will defer to the disclosure restrictions attendant to NASA mishap investigations. Upon receipt of such testimonial information, the OIG will consider it to be confidential witness testimony and will treat it as such to the full extent required by the Inspector General Act of 1978.

1.9.4 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.

1.9.5 Members of the investigating authority shall not participate in both collateral investigations or contractor and safety investigations for the same mishap or at the same time (Requirement 44337).

1.10 Investigations by Outside Authorities

1.10.1 NASA shall support investigations of NASA mishaps by other Federal agencies authorized to investigate NASA mishaps (Requirement 44339).

1.10.2 NASA shall support investigations of mishaps experienced by other Federal agencies, foreign participants, and private industry in accordance with agreements (Requirement 44340).

1.10.3 If the NASA appointing official accepts an investigation by other authorities or contractors 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.

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

a. When a Presidential Commission is appointed pursuant to the NASA Authorization Act of 2005 (Public Law 109-155, Section 821) to investigate the loss of a Space Shuttle, the loss of ISS or its operational viability, the loss of any other United States space vehicle carrying humans that is owned by the Federal Government or that is being used pursuant to a contract with the Federal Government, or the loss of a crew member or passenger of any space vehicle described in this subsection.

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

c. 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.

d. 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.

1.10.5 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.

1.10.5.1 A contractor onsite injury or illness that is classified as a Type C mishap, Type D mishap, or Close Call may be investigated by the contractor per their contract. The mishap report must be delivered to NASA, and NASA has the option of completing the endorsement process. (Requirement 44348)

1.10.6 When the onsite incident has been classified as a Type D mishap or a close call involving government property damage (including flight hardware, ground processing equipment, and/or the ground facility), the NASA appointing official may allow contractor investigation of the mishap per their contract provided the following are true:

a. NASA serves as the appointing official and approves the investigating authority.

b. The investigating authority has the same membership (e.g., disciplines and training) as defined in this NPR (NPR 8621.1) with the exception that all members and advisors are contractor personnel.

c. The investigating authority performs the investigation per this NPR with the exception of taking privileged witness statements. (Rationale: NASA can not protect privileged witness statements taken by a contractor. Consequently, the contractor is not authorized to grant privilege.)

d. The investigating authority produces the products listed in Figure 5.

e. The NASA appointing official reviews and endorses the report.

CHAPTER 2. Readiness to Conduct Investigations

2.1 Headquarters Operations and Center Mishap Preparedness and Contingency Plan

2.1.1 The AA/OIA and each CD shall develop a Center Mishap Preparedness and Contingency Plan that describes the following:

a. The local mishap and close call notification, reporting, investigating, recording, and prevention policies and procedures (Requirement 31272).

b. The relationship between the emergency preparedness plan, the Center Mishap Preparedness and Contingency Plan, and Program Mishap Preparedness and Contingency Plans and which plan takes precedence given specific conditions (Requirement 31273).

c. Management responsibilities for establishing mishap investigations (Requirement 31274).

d. Procedures to appoint an IRT for those mishaps and close calls that are not covered by a program/project Mishap Preparedness and Contingency Plan (i.e., facility mishaps and close calls) (Requirement 31275).

e. Procedures to appoint a MIT or MI for Type C mishaps, Type D mishaps, and close calls that occur at the Center or involve programs/projects/activities managed by the Center (Requirement 31276).

f. Roles and responsibilities of the incident commander (or the location in the emergency preparedness plan where these can be found) (Requirement 31277).

g. Procedures to impound appropriate records and equipment that may be involved in the mishap to prevent unauthorized use or modification (Requirement 31278).

h. List of responsible organizations, along with Center safety office personnel, that shall take immediate action to safeguard (or impound) appropriate records, equipment, and facilities and secure the mishap site (Requirement 31279).

i. Identification of the location or space where impounded data, records, and equipment shall be stored and secured during an investigation (Requirement 31280).

j. Procedures for release of impounded data, records, equipment, facilities, and the mishap site (Requirement 31281).

k. Mishap report approval process for Type C mishaps, Type D mishaps, and close calls that occur at the Center or involve programs/projects/activities managed by the Center (Requirement 31282).

l. List of potential contractor support and onsite experts that can facilitate the immediate acquisition or purchase of products needed by the investigation board or team (e.g., high resolution cameras, recording devices, software, and others) (Requirement 31283).

m. The mandatory schedule for mishap simulations that include simulation of accident investigation procedures as described in this NPR, the Center Mishap Preparedness and Contingency Plan, and the Program Mishap Preparedness and Contingency Plan (Requirement 31284).

n. The information technology plan to provide computer data retrieval and data archive support to the investigating authority (Requirement 31286).

o. Requisite security clearances, if any, for investigating authority members, chair, and ex officio (Requirement 31287).

p. Description of the "chain of custody process" that will be used to secure and safeguard personnel effects and sensitive information related to injured or deceased individuals (Requirement).

Note: This process includes the procedures to provide physical security over and controlled access to personal effects and other sensitive material.

q. The expiration date (Requirement).

Note: Depending on the Center personnel turnover and realignments, the Center Mishap Preparedness and Contingency Plan, including the contact list may need to be updated semiannually or quarterly.

2.2 Program and Project Mishap Preparedness and Contingency Plans

2.2.1 The program/project manager shall concur in a Program/Project Mishap Preparedness and Contingency Plan that:

a. Is a comprehensive plan for all mishaps and close calls that occur offsite, at offsite program/project (as defined by NPR 7120.5) contractor sites, or in flight.

b. Is consistent with the Centers' Mishap Preparedness and Contingency Plans, for all Centers in which the program operates (Requirement 31290).

c. Covers any information and procedures required specifically by the program that are not covered in the Centers' Mishap Preparedness and Contingency Plans (i.e., special procedures for safing, handling, or containing hazardous chemicals present in the program's/project's hardware) (Requirement 31291).

d. Describes the procedures to comply with NPR 8621.1 notification, reporting, investigating, and recording requirements for all program/project activities not located at a Center or managed by a Center (e.g., program/project activities managed by Headquarters and located at a University, contractor site, or other off-Center location) (Requirement 31292).

e. Describes the training requirements and the IRT's membership for mishaps and close calls that occur offsite, at offsite program/project (as defined by NPR 7120.5) contractor sites, or in flight (Requirement 31293).

f. Describes any special procedures for the emergency response personnel, the IRT, and the incident commander that are not covered in the Center Mishap Preparedness and Contingency Plan or the emergency response plan (e.g., identification and handling of hazardous commodities specific to the program) (Requirement 31294).

g. Describes the procedures to impound data, records, equipment, facilities, and property not located at a NASA facility (Requirement 31295).

h. Identifies existing memoranda of agreement with national, state, and local organizations and agencies that may be utilized during a mishap investigation (Requirement 31297).

i. Describes how offsite debris shall be collected, transported, and stored (Requirement 31298).

j. Describes the investigation and debris collection process required for any mishap or close call occurring in a foreign country (Requirement 31299).

k. Requires that, for NASA-investigated mishaps, NASA personnel shall perform and control the impounding process (Requirement 31300).

l. Lists the personnel who will assist in performing the procedures to impound data, records, equipment, facilities, and other property (Requirement 31301).

Note: Contractor personnel may provide data from their offices and/or facilities to the NASA personnel performing this task.

m. Identifies the national, state, and local (and, where applicable, international) organizations and agencies which are most likely to take part in debris collection; identifies the roles and responsibilities of each organization; and identifies a point of contact (Requirement 31296).

n. Addresses the responsibilities and procedures for mishap investigation in the bilateral or multilateral agreements when the program involves international partners, program managers, and project managers (Requirement 31302).

o. Describes the resources that may be needed from other government agencies (e.g., Federal Emergency Management Agency, NTSB, DoD, Department of Justice) during a Type A mishap or Type B mishap investigation; identifies the point of contact and contact information for each of these Agencies; describes the procedures to acquire their assistance; and identifies the potential roles and responsibilities of each Agency (Requirement 31303).

p. Includes a list of information such as databases, Web sites, documentation (including hardware history), drawings, basic system operation, and procedures that may be scrutinized in a Type A mishap involving loss of a vehicle and/or major facility damage and frequently updates this information so that it is easily deliverable to a mishap investigation board, and includes points of contact for the information. (Requirement 31304).

q. Describes the information technology plan to provide computer data retrieval and data archive support to the investigating authority (Requirement 31306).

r. Describes the requisite security clearances, if any, for investigating authority members, chair, and ex officio participating in program/project investigations (Requirement 31307).

s. Describes the "chain of custody process" that will be used to secure and safeguard personal effects and sensitive information related to injured or deceased individuals (Requirement).

Note: This process includes the procedures to provide physical security over and controlled access to personal effects and other sensitive material.

t. Names of key personnel from the Agency Public Affairs Office and Office of External Relations (OER) that should be notified for all Type A and Type B mishaps (Requirement).

u. States the expiration date (Requirement).

Note: Depending on the Program personnel turnover and phase (e.g., test, processing, and flight), the Program/Project Mishap Preparedness and Contingency Plan, including the contact list may need to be updated semiannually or quarterly.

2.2.2 The program/project manager shall have the appropriate NASA Offices, at a minimum, General Counsel, OPA, OER, OSMA, and Centers (all Centers at which the program/project has activities) review and comment on the Mishap Preparedness and Contingency Plan prior to its approval (Requirement 31308).

2.2.3 The program manager (or designee) shall provide the Program Mishap Preparedness and Contingency Plan to OSMA/SARD for compliance review at least three weeks prior to the Safety and Mission Success Review (SMSR).

2.2.4 The program manager shall submit the Program Mishap Preparedness and Contingency Plan to the Chief/OSMA for concurrence two weeks prior to the Program SMSR

2.2.5 The program or project (as defined per NPR 7120.5) Safety and Mission Assurance representative shall review and approve the Mishap Preparedness and Contingency Plan, verifying that it has the content required per this NPR (NPR 8621.1), prior to submittal for signature (Requirement).

2.3 Mishap Preparedness and Contingency Plan Practice

2.3.1 The Program and Center Mishap Preparedness and Contingency Plans, including emergency response where appropriate, shall be practiced during contingency simulations that occur prior to a major test, launch, or space activity (Requirement).

Note: Practice is intended to mean tabletop and/or full enactment simulations (where possible).

2.3.2 For ongoing programs with repeated major test, launches, and space activities, the Program Mishap Preparedness and Contingency Plan, including emergency response where appropriate, shall be conducted at least every 18 months.

2.3.3 The Center Safety Office at the Center where the program is managed shall provide oversight of the Mishap Preparedness and Contingency Plan simulation.

2.3.4 At the conclusion of the simulation, the Center Safety Office and Program shall identify any deficiencies in the Mishap Preparedness and Contingency Plan, update the plan as needed, and/or take other necessary corrective actions to assure that the plan can be effectively implemented if a mishap occurs.

2.4 Contingency Plan Web Site

2.4.1 All MDAAs, Programs, Projects, and Centers shall submit their up-to-date Mishap Preparedness and Contingency Plans to OSMA/SARD for storage on the NASA Process Based Mission Assurance Secure Web Site.

Note: The mishap web site provides a secure central repository that NASA civil servants can use to find the latest versions of the contingency plans.

2.5 Contract Clauses

2.5.1 Contracting officers shall include appropriate mishap and close call notification, reporting, recording, and investigation procedures in NASA contracts (Requirement 31310).

2.5.2 The Center safety office shall involve itself in acquisition strategy meetings per NFS Part 1807, Acquisition Planning, to assure that the appropriate mishap and close call reporting, investigating, and evaluation criteria are incorporated into contracts (Requirement 31311).

2.6 Training

2.6.1 The Chief/OSMA with the support of the Center safety office shall provide the necessary training to ensure that at least one member of each investigating authority and the ex officio has, at a minimum, the following:

a. Knowledge of the NASA mishap investigation policy and process as demonstrated via test (Requirement 31314).

Note: The NASA "Introduction to Mishap" course provides the training to meet this requirement.

b. Knowledge and skills to secure the site; preserve the mishap scene; interview witnesses; collect and impound data, records, equipment and facilities; create time lines; document facts; generate fault trees; perform barrier analysis; perform change analysis; create event and causal factor trees; obtain forensic analysis; integrate evidence; draw conclusions; generate recommendations; and generate mishap reports (Requirement 31315).

2.6.2 The Chief/OSMA, with the support of the Center safety office, shall provide the necessary training to ensure that the human factors mishap investigator has the following:

a. At a minimum, knowledge (as demonstrated via test or on-the-job training) of the method to identify unsafe acts and errors, identify types of errors, identify causal and contributing factors for errors, identify performance shaping factors, interview witnesses, analyze data, create timelines, perform fault tree analysis, perform barrier analysis, create event and causal factor trees, draw conclusions, and generate recommendations that will reduce human error or mitigate the negative consequence of human actions (Requirement 31317).

b. Basic knowledge of physical and psychological processes, capabilities, skill levels, and limitations of humans, such as the science and practical application of cognitive psychology, human reliability, anthropometrics, biomechanics, and human factors engineering applications to design (Requirement 31318).

2.6.3 The Center safety office shall develop and maintain NASA mishap investigation introductory training (onsite orientation training) that can be provided to the investigating authority and advisors upon their assignment to the investigation (Requirement 31319).

a. The NASA mishap investigation introductory training shall include (at a minimum) a brief familiarization of the investigating authority's roles and responsibilities, NASA policy and procedures, and a description of root cause analysis (Requirement 31320).

2.7 Tools

The Chief/OSMA supported by the Center safety offices shall identify candidate mishap investigation tools that can be implemented quickly and maintain a tool repository that makes these tools readily available to investigating authorities (Requirement 31321).

Chapter 3. Initial Response to a Mishap or Close Call

Note: A notional timeline of the mishap investigation process, from the time of a mishap to the time that the corrective action plan and lessons learned are generated, is in Appendix C.

3.1 Safe the Mishap Site and Initiate Mishap Preparedness and Contingency Plan(s)

3.1.1 After the initial notifications are made, the supervisor shall provide any necessary assistance to safe the mishap site until the emergency response and/or personnel from the Center safety office arrive (Requirement 44432).

3.1.2 Upon notification of a mishap, the Center safety office shall initiate the Center Mishap Preparedness and Contingency Plan (Requirement 44433).

3.1.3 In the event of a program/project mishap, the program shall activate its Mishap Preparedness and Contingency Plan (Requirement 44434).

3.1.4 In accordance with the Center Mishap Preparedness and Contingency Plan, the incident commander, with support from the responsible organization, IRT, Center safety office, Center security office, emergency response personnel, and supervisor, shall take immediate action to prevent further injury to personnel and/or damage to any property and secure the site (Requirement 44435).

3.1.5 The incident commander and emergency response personnel shall have the authority to take action to mitigate dangerous conditions, direct emergency response actions, and/or clean up a hazardous materials release (Requirement 44436).

3.1.6 The Center safety office and incident commander shall ensure protection of personnel from residual hazardous material prior to entry into the mishap site (Requirement 44437).

3.1.7 The Center safety office and/or incident commander shall stipulate the type of personal protective equipment (PPE) required (Requirement 44438).

3.1.8 Every professional supporting the investigation, including the IRT and investigating authority, shall adhere to the PPE requirements as defined by the Center safety office personnel or incident commander (Requirement 44439).

3.2 Notify Headquarters Office of Safety and Mission Assurance Within 1 Hour of Type A Mishap, Type B Mishap, High-Visibility Mishap, or High-Visibility Close Call

After emergency response has been initiated, within 1 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 Headquarters as described in paragraph 1.5.3 and NPR 7100.1, paragraph 11.4.1 (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 44440).

3.3 Deploy IRT

In accordance with the Center or program/project Mishap Preparedness and Contingency Plan, the Center safety office or other designee shall deploy the IRT to initiate and support the investigation until a determination can be made as to the need for, and selection of, an investigating authority (Requirement 44441).

3.4 Notify Personnel and the Public of Potential Hazards

The AA/OPA (or designee), with the assistance of the Center safety office, IRT, and CD or ED/OHO shall immediately release information to the press and media to alert Center personnel and the public of any known hazards and their potential effects and provide instructions that will mitigate the risk and harm (Requirement 44442).

3.5 Secure the Site and Preserve Evidence

3.5.1 The incident commander, with support from the responsible organization, IRT, Center safety office, Center security office, emergency response personnel, and supervisor, shall take immediate action to prevent further injury to personnel and/or damage to any property, secure the site, limit unnecessary access, and preserve evidence (Requirement 44444).

3.5.2 Evidence preservation actions shall not hamper essential rescue operations (Requirement 44445).

3.5.3 In the event that a fatality occurred, a Federal employee that is part of the IRT (preferably a medical professional) or the physician that serves as a member of the investigating authority shall coordinate and consult with the Office of General Counsel and the coroner or medical examiner to determine medical jurisdiction and arrange for forensic analysis (i.e., autopsy) (Requirement 44446).

3.6 Impound Data

3.6.1 The Center safety office, with the support of the IRT, Center security office personnel, and supervisor, shall impound all appropriate data, records, equipment, and facilities that may be involved in the mishap to prevent their unauthorized use or modification (Requirement 44448).

3.6.2 The Center safety office shall control access to all impounded items until they are released by the investigating authority per the procedures in the Center Mishap Preparedness and Contingency Plan (Requirement 44449).

3.6.3 Data and records, regardless of format, to be impounded may include, but are not limited to, check-out logs, test and check-out record charts, launch records, weather information, telemetry tapes, video tapes, audio tapes, time cards, training records, work authorization documents, inspection records, problem reports, notes, e-mail messages, and automated log keeping systems and procedures.

3.6.4 For NASA mishaps occurring on international programs and/or involving program participants, autopsies shall be conducted in accordance with the bilateral/multilateral agreements (Requirement 44451).

3.6.5 For NASA mishaps occurring on international programs and/or involving international program participants, data, records, equipment, and facilities shall be impounded in accordance with the bilateral/multilateral agreements (Requirement 44452).

3.7 Initiate Drug Testing

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, the supervisor shall initiate post-accident/unsafe practice testing per NPR 3792.1, NASA Plan for a Drug-Free Workplace (Requirement 44453).

3.8 Collect Witness Statements

a. All written witness statements obtained within the first 24 hours of the occurrence of a mishap or close call shall be considered privileged and protected (Requirement 44455). Where possible, written witness statements should be collected on a NASA form that includes the statement of privilege as shown in Figure 6.

b. All verbal witness statements and written statements given after 24 hours as part of a NASA mishap investigation, where the witness was explicitly informed that his/her account will not be released, shall be considered privileged and protected (Requirement 44457).

c. When privilege has been granted by the IRT, Center safety office, or investigating authority, NASA shall make every effort to keep witness testimony (both written and verbal) confidential and privileged to the greatest extent permitted by law (Requirement 44458) This privileged information will be strictly limited to only the information provided directly by the witness for the safety investigation.

d. The witness shall not be given a copy of the privileged written statement or transcripts of verbal witness statements given in the course of a NASA mishap investigation (Requirement 44460). (If witness statements or transcripts of witness testimony are provided to a witness, NASA cannot ensure that it remains privileged and confidential.)

e. The Center safety office, with the support of the IRT, shall either request initial written statements from all persons who were involved in or witness to the mishap or document verbal accounts from such persons (Requirement 44462).

f. Before a verbal witness statement is taken or an interview begins, the IRT, Center safety office, or investigating authority shall tell the witness whether the information gathered during the interview is confidential and privileged or not confidential and not privileged (Requirement 44463).

Note: If the same individual is interviewed multiple times, this should occur each time the individual is interviewed.

g. When conducting privileged witness interviews, the NASA investigating authority shall only have Federal employees present at the interview (with the exception of the interviewee), unless a contractor has been hired specifically to support interviews or provide technical guidance to the Board during the interviews and has signed a nondisclosure agreement prepared by General Counsel prior to participating in the interviews (Requirement 44465).

h. When it is expected that an external investigating body will be the sole mishap investigation authority (e.g., for catastrophic vehicle failure such as Space Shuttle or International Space Station loss, or airplane loss), NASA shall not grant privilege to witnesses for either written witness statements or verbal witness statements, even when those statements are taken within the first 24 hours after the mishap (Requirement 44466).

Note: If an outside investigating authority, such as a congressionally appointed mishap investigating board or the National Transportation Safety Board (NTSB), conducts a mishap investigation for a mishap involving an airplane or catastrophic vehicle loss, they are not required to comply with NPR 8621.1. Consequently, NASA is unable to ensure that privilege will be maintained and may not be able to withhold privileged statements from the investigation authority.

i. When the IRT, Center safety office, or investigating authority decides to take a verbal statement or interview a witness and keep that witness interview confidential, the interviewer shall read the statement in Figure 6 of this NPR and inform the witness that:

(1) The oral statement (taken during interview) and/or written statement will be retained as part of the investigation report background files but will not be released as part of the mishap report (Requirement 44469).

(2) NASA will make every effort to keep the testimony privileged to the greatest extent permitted by law (Requirement 44470).

Figure 6. Statement That Shall Be Read to Witness at the Start of the Formal Interview

3.9 Coordinate Release of Information

3.9.1 Release of Information Concerning Casualties and Extensive Property Damage

3.9.1.1 The NASA Headquarters OPA must approve the release of all information related to NASA Type A mishaps and Type B mishaps, prior to its release to the press or public (Requirement 44473).

3.9.1.2 The CD or ED/OHO shall coordinate release of all information to the press and the public via the Center PAO (Requirement 44474).

3.9.1.3 The Center PAO shall, as appropriate, disseminate any preliminary information, video, and imagery to the public relating to the mishap (Requirement 44475).

3.9.2 Release of Information Concerning NASA-Owned Property Damage on Other Than Government-Owned Facilities, Overseas Tracking Stations, and Contractor-Owned Plants

3.9.2.1 When a mishap involving extensive damage to, or destruction of, NASA property occurs at other than government-owned facilities, overseas tracking stations, or contractor-owned plants, the contractor, tracking station manager, base commander, or other authority shall inform their point of contact at NASA (Requirement 44477).

3.9.2.2 The Center safety office cognizant of the mishap shall confirm that the mishap occurred to the NASA-owned property on other than government-owned facilities (Requirement 44478).

3.9.3 Release of Information to the Press and Public Concerning Casualties

3.9.3.1 NASA Employee Casualties. When a NASA employee is killed or receives a permanent disability within the confines of a Center, the Center PAO shall promptly announce to the public that a mishap has taken place and injuries or fatalities have occurred (Requirement 44480).

a. In the case of a fatality, the CD or ED/OHO or appropriate Headquarters Official-in-Charge, shall ensure that notification of the family has been made prior to release of the victim's name (Requirement 44481).

b. All initial announcements shall include what is known at the time, including the injuries or fatalities that have occurred and when additional information is expected to be available (Requirement 44482).

c. In the case of fatalities, release of the victim's name(s) shall be made as soon as possible after the notification of the next of kin (Requirement 44483).

3.9.3.2 Military and Other Agency Personnel Casualties. The procedures for public announcements of mishaps involving military and other Federal personnel (including astronauts) detailed to NASA shall be the same as for NASA employees, with these additional requirements:

a. The CD or ED/OHO shall inform the appropriate military service headquarters or other Federal agency of the mishap (Requirement 44485).

b. The CD or ED/OHO shall inform the Center PAO that the military service organization or other Federal agency has been notified of the mishap (Requirement 44486).

c. When the Center is on a military base, release of a victim's name shall be made according to procedures previously agreed upon by the base commander and CD or ED/OHO (Requirement 44487).

3.9.3.3 Contractor and Grantee Employee Casualties. NASA does not assume responsibility for the release of information concerning mishaps involving contractor or grantee employees, except as follows:

a. When a Type A mishap or Type B mishap occurs on a Center or at Headquarters or involves a NASA-managed program managed by that Center, the CD or ED/OHO, in coordination with the Center PAO/Headquarters PAO, shall announce as soon as possible that a mishap has occurred, as well as the number of known fatalities and/or injured (Requirement 44489).

b. The CD or ED/OHO shall not announce the identity of contractor or grantee personnel involved (Requirement 44490).

c. When a mishap occurs at a contractor's/grantee's plant engaged in NASA work, NASA has no responsibility to release information concerning the mishap and shall not issue statements as to the cause and extent of injury or damage (Requirement 44491).

3.9.3.4 Center Visitor Casualties. When a Type A mishap or Type B mishap occurs which involves visitors on a Center or at Headquarters, the CD or ED/OHO, in coordination with the Center PAO or Headquarters PAO, shall announce as soon as possible that a mishap occurred and the number of known fatalities and/or injured (Requirement 44492).

3.9.3.5 Overseas Mishaps. When a Type A mishap or Type B mishap occurs overseas, for example, at a tracking station or during an overseas rocket or balloon campaign involving NASA personnel, the Official-in-Charge shall release mishap information through the U.S. consular office in accordance with policies and procedures established by that office (Requirement 44493).

a. If the program involves foreign participation, the release of information shall be coordinated with the foreign entities sponsoring and participating in the program (Requirement 44494).

b. The Official-in-Charge shall notify, by the most expeditious means, the Chief/OSMA and the appropriate MDAA that a mishap has occurred overseas (Requirement 44495).

c. The MDAA shall notify, by the most expeditious means, the AA that a mishap has occurred overseas (Requirement 44496).

d. The AA shall immediately notify the Administrator, the Deputy Administrator, the AA/OPA; the Assistant Administrator, Office of External Relations; the Office of the General Counsel, as well as other appropriate staff that a mishap has occurred overseas (Requirement 44497).

3.10 Notify OSHA

3.10.1 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 per paragraph 1.5.4 of this NPR (Requirement 44499).

3.10.2 OSHA notification is required for any fatality and for three or more hospitalizations for inpatient care that occur up to 30 workdays after the respective mishap (Requirement 44500).

3.11 Record the Mishap

3.11.1 For Type A mishaps, Type B mishaps, high-visibility mishaps, and high-visibility close calls, the Center safety office shall send an electronic notification to OSMA/SARD containing information found in paragraph 1.5.3.2 of this NPR (Requirement 44502).

3.11.2 Within 24 hours, the Center safety office shall ensure that all NASA mishaps and close calls are recorded in IRIS in accordance with paragraph 1.8.1 of this NPR (Requirement 44503).

Note: Close calls involving aircraft may be entered into the NAARS in lieu of IRIS.

Chapter 4. Select the Investigating Authority and Support

4.1 Determine the Appointing Official for Mishap and Close Call Investigation

4.1.1 The Chief/OSMA or the AA shall contact the Administrator within 1 hour of the initial notification of the Type A mishap to determine if the Administrator wishes to exercise appointment authority (Requirement 44507).

4.1.2 Within 48 hours of a mishap or close call, the appointing official, as specified in Figure 5, shall appoint the investigating authority (Requirement 44508).

4.1.3 The Administrator shall serve as appointing official for NASA joint participation on a MIB with the DoD and other agencies unless authority is delegated by existing agreements (Requirement 44509).

4.2 Select the Members of the Investigating Authority (MIB, MIT, or MI)

Note: Investigating Authority members include: chairperson, voting members, and ex officio. Support personnel, such as advisors and consultants, are not members of the investigating authority (MIB, MIT, or MI).

4.2.1 The appointing official shall select the members of the investigating authority, the chairperson, the executive secretary (when needed), and the support staff (Requirement 44511).

4.2.2 The MDAA shall request concurrence from the Chief/OSMA and the Chief Engineer on the proposed MIB membership for Type A mishaps, high-visibility mishaps, and high-visibility close calls in which he/she is the appointing official (Requirement 44512).

4.2.3 For Type A mishaps and Type B mishaps, the investigating authority membership shall be determined with the advice of the Office of the General Counsel or the Office of the Chief Counsel, as appropriate (Requirement 44513).

4.2.4 For Type A mishaps and Type B mishaps, high-visibility mishaps, and high-visibility close calls involving aircraft, the investigating authority membership shall be determined with the advice of the AD (Requirement 44514).

4.2.5 The Chief/OSMA shall concur with the selection of MIB membership for Type A mishaps, Type B mishaps, high-visibility mishaps, and high-visibility close calls (Requirement 44515).

4.2.6 For Type C mishaps, Type D mishaps, and close calls, the CD or ED/OHO, or designee, shall seek advice concerning investigating authority membership from the Center safety office (Requirement 44516).

a. The MDAA [or designee] shall seek advice concerning investigating authority membership from OSMA/SARD for NASA Type C mishaps, Type D mishaps, and close calls that involve Mission Directorate programs/projects/activities where the mishaps or close calls have occurred outside the Center's gates and are not managed by a Center, program, or project (Requirement 44517).

4.2.7 The appointing official shall use the following requirements to determine the composition of the investigating authority:

a. All members of the investigating authority (including the chairperson) and the executive secretary must be Federal personnel (Requirement 44519).

b. The severity and complexity of the mishap to be investigated shall dictate the total number of members (Requirement 44520).

c. The investigating authority shall consist of an odd number of voting members (including the chairperson) (Requirement 44521).

d. The majority of the members of the investigating authority shall be independent from (have no responsibilities for) the operation or activity (Requirement 44522).

Note: During a mishap investigation, root cause analysis may evaluate actions of those performing the activity or overseeing the activity. It is difficult to conduct an unbiased investigation of one's own actions.

e. Members and the chairperson shall have the requisite security clearances as identified in the Center and/or program/project Mishap Preparedness and Contingency Plans (Requirement 44524).

f. The chairperson for the investigating authority shall be independent of the program or facility that experienced the mishap or close call (Requirement 44525).

Note: It is preferred, for Type A mishaps and Type B mishaps, that the chairperson is not from a Center directly involved in the oversight or assurance of the program or facility operation.

g. The members shall not be from the direct chain of authority responsible for day-to-day or line management oversight of the facility, area, or activity involved in the mishap or have a vested interest in the outcome of the investigation (Requirement 44527).

h. The MIB and MIT shall be composed of a chairperson, members, and an ex officio (Requirement 44528).

i. The MIB shall have at least five members for a Type A mishap and at least three members for a Type B mishap (Requirement 44529).

(1) The number of MIB members for high-visibility mishaps and high-visibility close calls shall be determined by the appointing official (Requirement 44530).

j. For all Type A mishaps involving injury, illness, or fatality, the MIB shall include an occupational health physician as a member (Requirement 44531). (Mishaps involving an aircraft may have a flight surgeon rather than an occupational health physician.)

Note: The chairperson may request a medical doctor to serve as an advisor or consultant, if one is not a member of the mishap investigation board.

k. For all Type A mishaps, Type B mishaps, high-visibility mishaps, and high-visibility close calls involving aircraft, the MIB shall have a member knowledgeable in aircraft operations, a member knowledgeable in aircraft maintenance, and a member knowledgeable in aviation safety (Requirement 44534). (The member knowledgeable in aviation safety may serve as the safety officer.)

l. The MIB and MIT shall include a safety officer and a human factors mishap investigator as members (Requirement 44536).

Note: SMA-SAFE-OSMA-4004 Human Factors in Mishap Investigation (within the last five years) meets this requirement. Educational study or degree in Human Factors may be approved as equivalent by the Mishap Investigation Program Manager or assignee.

n. The investigating authority shall have at least one member that has completed all the NASA mishap investigation training listed in paragraph 2.6.1.a in the last 12 months and paragraph 2.6.1.b in the last five years (Requirement 44538).

o. When possible, all investigating authority members should be selected from personnel who have completed the NASA mishap investigation training (or equivalent) and have received refresher training in the last five years (if training was acquired more than five years ago).

p. Members shall have sufficient experience and technical expertise to understand the technology and management interfaces related to the mishap (Requirement 44540).

q. When needed, if the area of investigation expertise can not be obtained within NASA, the investigating authority's members may be appointed from Federal agencies having technical expertise in the area of investigation.

r. For international programs, members shall be selected as described in bilateral/multilateral or international agreements (Requirement 44542).

s. As documented in the Center Mishap Preparedness and Contingency Plan, the supervisor may serve as the investigating authority (mishap investigator) for Type D mishap and close calls in his/her organization as long as the following are true:

(1) The close call has not been deemed "high visibility" by the Center safety office, CD, or a higher authority.

(2) The supervisor has received introductory training on NPR 8621.1, root cause analysis, and investigating close calls and mishaps.

(3) The safety office assigns a person to serve as the ex officio to ensure that the investigation and report is nonpunitive and that the report meets the requirements in NPR 8621.1.

(4) The safety office assigns a person to endorse the mishap report.

4.3 Select the Ex Officio

4.3.1 For any mishap or close call, the Chief/OSMA may serve as the ex officio or appoint, at his/her discretion, the ex officio; otherwise that selection shall be made by the senior SMA official in the appointing official's organization (Requirement 44549).

4.3.2 For Type C mishaps, Type D mishaps, and close call investigations, the ex officio shall be at a level consistent with the authority level of the MIT chair (Requirement 44550).

Note: For investigations completed by a single mishap investigator, an ex officio is not required.

4.3.3 The ex officio shall be a Federal employee selected from personnel who have completed the NASA mishap investigation training or equivalent and have received refresher training in the last five years (if training was acquired more than five years ago) (Requirement 44552).

4.3.4 For Type C level investigations and below, the ex officio function may be fulfilled by a professional from the Center safety office who participates in the investigation activities he or she deems appropriate and approves the mishap report demonstrating assurance that the conditions in paragraph 1.4.12.d of this NPR have been met.

4.3.5 Only one ex officio shall be appointed to an investigating authority (Requirement 44554).

4.4 Select Investigating Authority's Advisors

4.4.1 For all mishaps, the appointing official shall request that the appropriate mission support office appoint advisors to the investigating authority (Requirement 44556).

4.4.2 For Type A, Type B, and Type C mishaps, the investigating authority shall have a legal advisor, a public affairs advisor, an import/export control advisor, and (where appropriate) an external relations advisor (Requirement 44557).

4.4.3 The advisors shall be NASA civil service employees selected from the respective mission support offices and be authorized to represent their mission support office's interests in the investigation (Requirement 44558).

4.4.4 When possible, the advisors should be selected from personnel who have completed the NASA mishap investigation training or equivalent and have received refresher training in the last five years (if training was acquired more than five years ago).

4.5 Select Investigating Authority's Consultants

4.5.1 Non-Federal employees may serve as consultants to the investigating authority.

4.5.2 When possible, consultants should be selected from personnel who have completed the NASA mishap investigation training or equivalent and have received refresher training in the last five years (if training was acquired more than five years ago).

4.5.3 As appropriate, consultants should have sufficient experience and technical expertise to understand the technology and management interfaces related to the mishap.

4.6 Provide Support to Investigating Authority

4.6.1 The appointing official shall arrange for administrative, logistical, and information technology support to the investigating authority via the appointment letter or by contacting the appropriate CD or the ED/OHO, as appropriate (Requirement 44565). Administrative support may include, but is not limited to, meeting rooms, clerical help, photographic support, records management assistance, and laboratory analysis.

4.6.2 The responsible organization, the Center safety office, and the CD or ED/OHO shall provide support as deemed necessary by the investigating authority (Requirement 44567).

4.7 Contents of the Appointment Letter or Appointment Orders

4.7.1 For Type A mishaps, Type B mishaps, high-visibility mishaps, and high-visibility close calls, the appointing official shall prepare an appointment letter to communicate the selection of the investigating authority members, the chairperson, the ex officio, and the advisors (Requirement 44569). (For Type C mishaps, Type D mishaps, and close calls, the appointment orders can be less formal and communicated via a Center process.)

4.7.2 The appointment letter shall identify the chairperson, membership (including ex officio), the legal advisor, the Headquarters public affairs advisor, import/export control advisor, the external relations advisor (where appropriate), the scope of the investigation, and the projected completion date (Requirement 44571).

4.7.3 The appointment letter/appointment orders shall relieve the investigating authority chairperson and members from other duties while they are engaged in investigation activities (Requirement 44572).

Chapter 5. Mishap Investigation Process

5.1 Overview of the Mishap Investigation Process

5.1.1 The investigating authority shall use a structured technique to collect and review all available data, construct a timeline of events, conduct witness interviews, reconstruct the mishap or close call, and analyze the mishap occurrence to determine what happened, when it happened, and why it happened (Requirement 44575).

5.1.2 Figure 7 illustrates the typical steps that the investigating authority shall perform during the mishap investigation (Requirement 44576).

Figure 7. Typical Steps in the Mishap Investigation

5.2 Prepare for the Investigation

The investigating authority shall perform the following activities prior to arrival at the mishap site or shortly thereafter:

a. Mishap investigation overview training (Requirement 44578).

(1) The Investigating Authority members and advisors shall take the NASA "Introduction to Mishap Investigation Training" upon their assignment to the investigation to familiarize themselves with NASA mishap investigation policies and procedures and root cause analysis (Requirement 44579). (Investigating authority members and advisors may opt out of the training if they have taken it within the last 12 months.)

b. Assessment of personnel resources (Requirement 44581). The chairperson may make a request to the appointing official to modify the investigating authority's membership to fill technical and/or analytical expertise gaps, provide management experience and knowledge, or eliminate members that have a conflict of interest.

(1) For Type A mishaps, Type B mishaps, high-visibility mishaps, and high-visibility close call investigation boards, the Chief/OSMA and Chief Engineer shall concur on membership changes prior to any MIB member additions or deletions (Requirement 44583).

c. Identification and selection of consultants as necessary (Requirement 44584).

d. Establishment of member duties, meeting times, and investigation schedules (Requirement 44585).

5.3 Verify that the Site is Safe and Secured and Ensure Evidence is Preserved/Impounded

5.3.1 Verify that the Mishap Site is Safe and Secured.

5.3.1.1 Upon arrival, the chairperson shall verify the site is safe and secured (Requirement 44588).

5.3.1.2 Neither the investigating authority nor the IRT has the authority to direct emergency response actions or activities to clean up a hazardous materials release (Requirement 44589).

(1) These actions shall be directed by the incident commander (Requirement 44590).

5.3.2 Ensure that Evidence is Preserved and Impounded.

5.3.2.1 The chairperson shall ensure that all the appropriate perishable evidence has been collected, photographed, documented, and/or impounded (Requirement 44592).

5.3.2.2 The chairperson shall ensure that all the necessary data, records, and equipment have been impounded and are being stored in a secure site (Requirement 44593).

5.3.2.3 The IRT, Center safety office personnel, emergency response personnel, and Center security office personnel shall provide the investigating authority with all evidence gathered at the scene; all data pertaining to the investigation, including impounded records; a status of impounded records/equipment; and a description of the actions taken (Requirement 44594).

5.3.2.4 When there is a mishap involving an injury or a fatality, the chairperson shall appoint a Federal employee to serve as an evidence custodian(s) who will implement the "chain of custody process" documented in the Program Mishap Preparedness and Contingency Plan to provide physical security over and controlled access to the injured/deceased personal effects and related sensitive material (Requirement 44595).

5.4 Gather Physical Evidence and Facts

5.4.1 The investigating authority should evaluate three general sources of data (material, personnel, and records) during the investigation. The material area includes all parts, components, and support facilities directly or indirectly involved. The personnel area includes all persons associated with the activities immediately surrounding the mishap, such as the flight crew, launch complex personnel, maintenance personnel, test personnel, operations personnel, range safety personnel, management and supervisory personnel, and witnesses and their associated training records, certification, e-mail, notes, and other records. The records data, regardless of format, include all records, telemetry, recordings, analyses, inspections, and historical data associated with the specific equipment, operations, and operating personnel.

5.4.2 The investigation should not be limited to data and records generated concurrently with, or as a result of, the mishap. It should also include historical, environmental, operational, psychological, and other factors bearing on the situation.

5.5 Interview Witnesses

5.5.1 It is NASA's philosophy to interview witnesses rather than interrogate them. "Interview" connotes a cooperative meeting where the interviewer approaches the interviewee as an equal. The cooperation of the interviewee is sought; encouragement is given to tell the story freely without interruption or intimidation. An interview is usually conducted informally with a voluntary or cooperative answering of questions. However, the investigating authority may also conduct more formal interviews. Even in those cases, witnesses shall not be sworn in (Requirement 44601).

5.5.2 The investigating authority shall interview mishap witnesses with two basic objectives in mind:

a. To find out what the witness observed or did (Requirement 44603).

b. To find out the witness's opinion of potential cause(s) of the mishap (Requirement 44604).

5.5.3 The investigating authority conducting the witness interviews shall perform all steps as listed in paragraph 3.8 of this NPR (Requirement 44605).

5.6 Review and Analyze Data

5.6.1 The investigating authority shall determine the sequence of events and document them in a timeline (Requirement 44607).

5.6.2 The investigating authority shall create a fault tree, or perform an equivalent analysis, to identify all potential cause(s) and contributing factor(s) to the mishap and the relationships among them (Requirement 44608).

Note: A fault tree should be used by the MIB to demonstrate that all potential causes of the mishap have been evaluated. An event and causal factor tree should be used to represent all the events that did occur, and the relationship between the proximate, intermediate, and root causes.

5.6.3 The investigating authority shall analyze all potential cause(s), including both technical and human cause(s) (Requirement 44610).

5.7 Draw Conclusions and Document Findings

5.7.1 The investigating authority shall evaluate all information collected during the course of the investigation, including, but not limited to, physical evidence, witness statements and testimony, and analytical results from testing and analysis; draw conclusions concerning what happened and why it happened; and document these as investigation findings (Requirement 44612).

5.7.2 All findings shall be supported by facts (Requirement 44613).

5.8 Generate Recommendations

5.8.1 At a minimum, the investigating authority shall develop recommendations that address both the proximate cause(s) and the root cause(s) to prevent recurrence of the mishap or close call or similar mishaps and close calls (Requirement 44615).

5.8.2 The investigating authority shall verify that the recommendations are clear, verifiable, achievable, and traceable to at least one significant finding (Requirement 44616).

Note: Each finding does not require a recommendation except as required in paragraph 5.8.1.

5.8.3 The investigating authority shall prioritize the recommendations (Requirement 44617).

5.8.4 At any time during the investigation, the investigating authority may recommend to the appointing official that immediate corrective actions be taken to ensure the safety of ongoing operations internal or external to NASA.

5.8.5 The appointing official shall communicate recommendations outside his/her authority to the responsible NASA organization or external body for implementation of corrective measures Requirement 44619).

5.9 When and How to Turn Over for Criminal Investigation

If it is reasonably suspected that a mishap resulted from criminal activity, the investigating authority shall halt the investigation; notify immediately the OIG and the Office of the General Counsel or the Office of the Chief Counsel, as appropriate; notify the appointing official; and wait for further direction (Requirement 44620). (The safety investigation should be completed regardless of the initiation of collateral investigations.)

5.10 Release the Mishap Site and Restore Site Operations

5.10.1 Only the investigating authority shall release the mishap site for post-investigation cleanup or other activities (Requirement 44623).

5.10.2 Only the investigating authority shall release impounded data, records, equipment, or facilities (Requirement 44624).

5.10.3 The investigating authority shall not release data and records unless copies of the documents are made and retained with mishap investigation records (Requirement 44625).

5.11 Status Reports

5.11.1 For NASA Type A, Type B, and high-visibility mishaps and close calls: Every 30 work days (minimum) from the time the appointment letter is signed until the mishap investigation report is signed, the investigating authority shall develop a publicly releasable status, using the template provided on the NASA mishap investigation Web site at https://nsckn.nasa.gov and provide the signed document to the appointing official, responsible Center safety office, and the NASA Safety Center through the regional mishap support specialist.

Note: A status report is a publicly releasable document that is approved by the public affairs and legal advisors assigned to the investigating authority.

5.12 Mishap Warning-Action-Response (MWAR)

5.12.1 At any time during the investigation when the investigating authority identifies a safety finding that requires immediate action and could impact one or more Centers, the investigating authority shall develop a MWAR using the template provided on the NASA mishap investigation Web site at https://nsckn.nasa.gov and provide the signed document to the appointing official, responsible Center safety office, and the NASA Safety Center through the regional mishap support specialist.

Note: An MWAR is a publicly releasable document that is approved by the public affairs and legal advisors assigned to the investigating authority.

5.13 Distribution

5.13.1 The NASA Safety Center Mishap Investigation Support Office (MISO) will maintain the distribution list for the status reports and the MWARs, distribute the status reports and MWARs electronically, and place the MWARs on the NASA mishap investigation Web site at https://nsckn.nasa.gov and the NASA Safety Center Web site at http://nsc.nasa.gov. Status reports will be stored in the same locations as the MWAR.

Note: The NASA Safety Center distributes the status reports and the MWARs through multiple channels to ensure that the information gets to the appropriate personnel.

Chapter 6. Mishap Report

6.1 Develop the Mishap Report

6.1.1 The investigating authority shall develop a mishap report that contains the information as specified in paragraph 1.7 and Figure 5 in this NPR (Requirement 44628).

6.1.2 Witness statements, witness names, and names of those involved in the mishap or related activities shall not be included as a part of the mishap report (Requirement 44629).

6.1.3 The mishap report shall be technically accurate; properly documented; easily understood; have traceability between facts, findings, and recommendations; and include the products required in Figure 5 in this NPR, in the following order:

a. Section 1: Signature page(s), list of consultants, executive summary, and OSHA summary (when applicable) (Requirement 44631).

Note: The OSHA summary goes in Section 1. The OSHA 301 Form or equivalent should be placed in the Appendix rather than Section 1 with the summary.

b. Section 2: Narrative description and facts (what, when, where, how) (Requirement 44632).

c. Section 3: Type of data gathered and data analysis (level of detail and products dependent upon Figure 5 in this NPR) (Requirement 44633).

d. Section 4: Finding(s) (Requirement 44634).

e. Section 5: Recommendation(s) (Requirement 44635).

f. Section 6: Minority Report(s) (Requirement 44636).

6.1.4 The investigating authority shall include the mishap classification level (e.g., Type A, Type B, Type C, Type D, or close call) and the IRIS/NAARS case number, the incident date, and the report date on the mishap report title page and the report executive summary (Requirement 44637).

Note: Both the Root Cause Analysis Tool and the IRIS "PRINT" function (from the Safety Incident General Tab) provide this information on the title page.

6.1.5 The investigating authority shall describe, in the mishap report, the type of property damage, type of the mission failure, and/or describe the personal injury(ies)/illness/(es) (Requirement 44638).

6.1.6 The investigating authority shall describe, in the mishap report, the actual direct cost of the mishap or if the actual direct cost is not available, the estimate of the direct cost of the mishap (Requirement 44639).

6.1.7 In the event that the investigating authority does not reach agreement on findings or recommendations, any member may develop and attach a minority report to the mishap report.

6.1.8 If the investigating authority would like to receive a preliminary review of the mishap report and feedback concerning the adequacy of the report, they may provide a draft mishap report to the appointing official and request a preliminary review.

a. This preliminary review must occur within the time allocated for the completion of the mishap report (Requirement 44642).

b. Upon receipt of a draft mishap report, the appointing official shall determine the appropriate preliminary review process and reviewing offices that should participate in the preliminary review, have them review the draft mishap report, and provide feedback to the investigating authority within 15 workdays (Requirement 44643).

c. The Center safety office or OSMA (dependent on level of investigation) shall participate in all preliminary reviews (Requirement 44644).

d. Feedback from reviewers may include, but is not limited to, requests for clarification, additional facts, further root cause analysis (or other analysis), feasibility evaluation of recommendations, compliance with NPR, and/or removal (or placement in a nonreleasable appendix) of privileged or proprietary information, ITAR information, EAR information, material subject to the Privacy Act, or other inappropriate information (i.e., witness names).

e. The chairperson and/or investigating authority is not required to make any changes to the mishap report with which he or she does not agree (Requirement 44646).

6.1.9 All investigating authority members shall sign the completed mishap report (Requirement 44647).

6.1.10 The ex officio shall sign the completed mishap report attesting to the following:

a. The investigation was conducted in conformance with NASA policy and this NPR (Requirement 44649).

b. The investigation process was fair, independent, and nonpunitive (Requirement 44650).

c. The mishap report contains all the required elements (Requirement 44651).

d. The mishap report accurately identifies the proximate cause(s), root cause(s), and contributing factor(s) (Requirement 44652).

e. Adequate facts have been gathered and analyzed to substantiate the findings (Requirement 44653).

f. The recommendations reasonably address the causes and findings (Requirement 44654).

g. Each recommendation is associated with (traceable to) at least one significant finding (Requirement 44655).

Note: Each finding does not require a recommendation except as required in paragraph 5.8.1.

h. If these conditions have not been met, the ex officio shall describe the mishap report's deficiencies in writing and sign and attach this description to the mishap report in lieu of signing the report (Requirement 44656).

6.1.11 Each NASA advisor shall 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 (Requirement 44657) and:

a. The export control advisor's signature indicates that any ITAR information and EAR information has been identified and marked as non-releasable to the public (e.g., NASA Sensitive But Unclassified) (Requirement 44658).

b. The contracting officer's signature indicates that any proprietary information or material subject to the Privacy Act has been identified and marked as non-releasable to the public (e.g., NASA Sensitive But Unclassified) (Requirement 44659).

c. The legal advisor's and public affairs advisor's signature indicates 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 (e.g., NASA Sensitive But Unclassified); and that volumes/appendices that are releasable to the public are marked releasable (Requirement 44660).

Note: Although marked, this release is pending endorsements and Public Affairs Office authorization.

6.1.12 The names of the consultants may be listed in the mishap report; however, the consultants shall not sign the mishap report (Requirement 44662).

6.1.13 Within 75 workdays of the mishap or close call, the investigating authority shall submit the completed and signed mishap report to the appointing official (Requirement 44663).

Note: Until this report has been signed and is officially endorsed by the endorsing officials, it is not an "official NASA Mishap Report" and should not be distributed to anyone other than the investigating authority, appointing official, endorsing officials, their reviewers, and the Headquarters SMA Mishap Coordinator.

6.1.14 If the investigating authority needs additional time to complete the investigation and/or the mishap report, they may submit a verbal or written request to the appointing official.

6.2 Release Investigating Authority

Upon receiving the signed mishap report, verifying that the mishap report fulfills the requirements of the appointment letter, and verifying that all records retention activities have been completed, the appointing official shall inform the investigating authority that they have fulfilled their requirements and are released from duty (Requirement 44666).

6.3 Review, Endorse, and Approve Mishap Report

6.3.1 Upon receipt of the signed mishap report, the appointing official shall request the appropriate officials to review and endorse the mishap report (see Figure 5 of this NPR for endorsing officials) (Requirement 44668).

6.3.2 The review and endorsement process should verify, at a minimum, the following:

a. The mishap report content is technically accurate and complete (Requirement 31461).

b. Proper analysis techniques were selected and completed correctly (Requirement 31462).

c. The mishap report adequately describes proximate cause(s), root cause(s), and contributing factor(s) (Requirement 31463).

d. There are adequate facts to substantiate the findings (Requirement 31464).

e. Recommendations are associated with (traceable to) at least one significant finding (Requirement 31465).

Note: Each finding does not require a recommendation except as required in paragraph 5.8.1.

f. Recommendations are practical, feasible, achievable, and will, in the opinion of the reviewer, prevent recurrence of similar mishaps or close calls (Requirement 31466).

g. Proprietary information, ITAR information, EAR information, material subject to the Privacy Act, or privileged information that should not be released has been identified (Requirement 31467).

6.3.3 For those mishap or close call reports where the Chief/OSMA is an endorsing official, all endorsements shall be forwarded to OSMA for review prior to completion of the Chief/OSMA endorsement (Requirement 44677).

6.3.4 Within 30 workdays, the endorsing officials will provide their signed endorsement, recommendation for mishap report approval or rejection, and (when applicable) comments related to amplification or disagreement with elements of the report to the appointing official. (These endorsements and comments (when applicable) shall be attached to the mishap report and become part of the permanent record) (Requirement 44678).

6.3.5 Within 5 workdays, the appointing official shall attach all endorsements and comments (including his/her own) to the mishap report, review the comments, and determine if the report is approved or rejected based on the review and comments/direction from endorsing officials (Requirement 44679).

6.3.6 If the appointing official rejects the mishap report, he/she must provide a written description of the deficiencies that warrant this rejection, attach this to the mishap report, send the report to the Center safety office (or OSMA for Type A mishaps, Type B mishaps, high visibility mishaps, and high-visibility close calls) for records retention, and charter a new investigation (Requirement 44680).

6.4 Authorize Mishap Report for Public Release

6.4.1 If the mishap report is approved, the appointing official shall immediately send the approved report with endorsements/comments to the Export Administrator, the Center PAO, Office of Protective Services, and then to OPA, Procurement, and legal counsel for review (Requirement 44682).

Note: For Type D mishaps and Close Calls, the Center Director, via documentation in the Center Mishap Preparedness and Contingency Plan, may allow the authorization for public release to occur only after a Freedom of Information Act (FOIA) request is made. However, this does not negate the responsibility to place lessons learned into the lessons learned information system.

6.4.2 Within 10 workdays of the request, the Export Administrator, OPA, Office of Protective Services, Procurement, and legal counsel shall review the mishap report and specify in writing which sections of the mishap report are authorized for public release (Requirement 44684).

Note: The Office of Protective Services role is to review the report to determine if any information in the report should be classified Secret or Top Secret.

6.5 Distribute Mishap Report

6.5.1 Upon receipt of notification that the mishap report is authorized for public release, the appointing official shall send the approved mishap report with authorization comments to OSMA/SARD and the Center safety office (dependent upon level of investigation) (Requirement 44687).

6.5.2 Within 10 workdays, the MDAA or the Center safety office shall distribute the mishap report to the appropriate NASA programs and organizations including, but not limited to, the responsible organization and/or program, all Center safety offices, the CHMO (when an injury or fatality has occurred), and AD (when the mishap involved an aircraft) (Requirement 44688).

6.5.3 Within 15 workdays, the Center safety office shall distribute information about the Type A mishap or Type B mishap via "weekly safety highlights" (or equivalent) to Center personnel, including a brief description of what caused the mishap and how it can be prevented (Requirement 44689).

6.5.4 The AA/OPA shall determine whether a mishap report, whatever its origin, shall be issued from Headquarters or the Center (Requirement 44690).

6.5.5 Generally, the appropriate public affairs officer shall make the news release on the mishap report available simultaneously at Headquarters and the appropriate Center (Requirement 44691).

6.5.6 The appropriate public affairs officer shall make the mishap report available to the public at the same time (Requirement 44692).

6.5.7 For aircraft mishaps, final submittal of the NASA mishap reports to the NTSB will be made by the Office of Institutions and Management. The Office of Institutions and Management will ensure that the NTSB submission meets the essential information required by the NTSB and may reformat and streamline the approved NASA report as necessary to meet that need without changing the report's causes, findings, and conclusions.

6.5.8 Within 48 hours of a mishap or close call, NASA shall provide all NASA employees and contractors access to information that is releasable to the public via a database including date, location, and brief description of the event (Requirement 44694).

6.5.9 As the mishap or close call record is updated, the employees will be given access to the updated information that is releasable to the public, including the executive summary, findings, and recommendations.

Chapter 7. Post-Investigation Activities

7.1 Develop CAP

7.1.1 Immediately after the mishap report has been authorized for public release, the appointing official shall direct the responsible organization or program/project to develop a CAP for those recommendations approved by the endorsing officials (Requirement 44698).

7.1.2 The appointing official may extend the CAP deadline upon written request from the responsible organization or program/project.

7.1.3 Within 15 workdays from being tasked, the responsible organization or program/project shall develop and submit the CAP to the appointing official (Requirement 44700).

7.2 CAP Contents

7.2.1 The CAP shall include the following:

a. A description of the corrective actions along with a designation of the organization(s) responsible for implementing the corrective actions and a completion date for each corrective action (Requirement 44703).

b. Which NASA organization, contractor organization, or grantee organization (to the lowest level) is responsible for ensuring the corrective action is completed (Requirement 44704).

c. A matrix or other means of matching corrective actions to all findings and recommendations (Requirement 44705).

d. A review of any process changes required based on corrective actions (Requirement 44706).

7.3 Review and Approve CAP

7.3.1 The appointing official may provide the CAP to the investigating authority, applicable safety organization, and other selected offices as is deemed appropriate for review.

7.3.2 Based on the results of these reviews and his/her own review, the appointing official shall either accept or reject the CAP (Requirement 44709).

7.3.3 If the plan is rejected, the appointing official shall return the CAP, with comments, to the responsible organization or program/project for revision and resubmission (Requirement 44710).

7.3.4 The appointing official shall determine the timeframe for resubmission of the CAP (Requirement 44711).

7.4 Implement CAP

7.4.1 The responsible organization shall implement the corrective actions as directed by the appointing official and as documented in the approved CAP (Requirement 44713).

7.4.2 The responsible organization shall track the corrective action performance and completion in IRIS and inform the appointing official of the status of the actions at intervals determined by the appointing official (Requirement 44714).

7.4.3 Close calls involving aircraft that have been entered into the NAARS, in lieu of IRIS, must track the corrective action performance and completion in NAARS.

7.4.4 The Center safety office shall assist the responsible organization, if needed, to enter updates into IRIS, as described in the Center Mishap Preparedness and Contingency Plan (Requirement 44716).

7.4.5 The Center safety office shall enter into IRIS the actual direct cost of the mishap or if the actual direct cost is not available, the estimate of the direct cost of the mishap (Requirement 44717).

7.4.6 Should a need arise to change the CAP after it has been approved (because the actions are deemed unwise or not feasible), the responsible organization shall submit the change to the appointing official for approval, similar to the process used for the original plan approval (Requirement 44718).

7.4.7 The appointing official shall assess and, if warranted and desired, approve any changes to the CAP (Requirement 44719).

7.4.8 The appointing official shall send approved changes to the responsible organization and the Center safety office (Requirement 44720).

7.5 Monitor and Closeout CAP

7.5.1 The applicable Center safety office shall monitor corrective action activities to determine if they were carried out according to the plan and report noncompliance to the appointing official (Requirement 44722).

7.5.2 When the corrective actions are closed, the appointing official shall develop and provide a CAP closure statement to the supporting Center safety office and the responsible organization to notify them that the corrective action plan is closed (Requirement 44723).

7.5.3 The Center safety office shall verify that the CAP is complete and all elements of the investigation have been completed and correctly recorded in IRIS (or NAARS for aviation close calls using NAARS in lieu of IRIS) (Requirement 44724).

7.6 Develop, Disposition, Submit, and Approve Lessons Learned

7.6.1 Following the authorization of the mishap report for public release, the appointing official shall designate a person or team of persons to develop the lessons learned identified in the mishap report (Requirement 44726).

7.6.2 The individual or team shall develop lessons learned that, at a minimum, include the executive summary, findings, and recommendations from the mishap report that are authorized for public release. (Requirement 44727).

7.6.3 Program and/or project managers that have mission failures or NASA mishaps for long-duration missions shall develop lessons learned for possible application to existing or future programs (Requirement 44728).

7.6.4 Within 10 workdays of being tasked, the person or team assigned to develop lessons learned shall submit the prepared lessons learned to the appointing official (Requirement 44729).

7.6.5 Prior to submission into NASA Lessons Learned Information System (LLIS), NASA program and policy officials, including, but not limited to, legal, import/export control, and public affairs, shall:

a. Review the proposed lessons learned to ensure they are consistent with NASA policy and do not contain any privileged or proprietary information, ITAR information, EAR information, or material subject to the Privacy Act (Requirement 44731).

b. Provide the appointing official with a written statement indicating that the lessons learned are cleared for submission into the NASA LLIS (Requirement 44732).

7.6.6 Based on the results of the review of the lessons learned, the appointing official shall either accept or reject the lessons learned and forward accepted lessons learned to the NASA LLIS (Requirement 44733).

7.6.7 OCE and program managers shall review the LLIS quarterly to determine if any mishap lessons learned should be translated into programmatic or Agency requirements (Requirement 44734).

7.7 Conclude Mishap Activities

7.7.1 The appointing official shall submit the mishap activities completion statement to the responsible organization, OSMA/SARD (For Type A mishaps, Type B mishaps, high-visibility mishaps, and high-visibility close calls), the Center safety office, and other appropriate organizations indicating that the investigation was performed; the CAP was developed, implemented, and closed; and the lessons learned have been entered into the NASA LLIS (Requirement 44736).

7.7.2 Once the appointing official has delivered the mishap activities completion statement, his/her duties for the mishap investigation are concluded, and the mishap file is closed.

7.8 Record and Retain Evidence

7.8.1 The final CAP and approved lessons learned shall be filed with the official approved mishap report in a location specified in the Center Mishap Preparedness and Contingency Plan (Requirement 44739).

7.8.2 NASA medical reports and witness statements are excluded from a mishap report, but should be retained, marked confidential and privileged, and filed with the official approved mishap report.

7.8.3 The CAP, lessons learned, and witness statements, plus other records documenting the investigation, shall be managed and dispositioned by the Center safety office in accordance with NPR 1441.1, NASA Records Retention Schedule (Requirement 44741). Such records, regardless of format, include, but are not limited to, mishap reports and associated records; relevant notes and e-mail messages of the IRT and investigation authority; meeting agendas, minutes, and other documentation of the investigation process; and copies of all data and records that are used in evaluation and analysis of the mishap.

7.8.4 Ensure that NASA information is protected and handled in accordance with the requirements of NPR 1600.1, NASA Security Program Procedural Requirements; NPR 2190.1, NASA Export Control Program; and NPR 2810.1, Security of Information Technology.

Note: It is NASA policy to protect NASA information that is commensurate with the national security classification level, sensitivity, value, and criticality in accordance with NPR 1600.1, NASA Security Program Procedural Requirements; NPR 2190.1, NASA Export Control Program; and NPR 2810.1, Security of Information Technology. The FISMA act and other Federal laws and directive; e.g., International Traffic in Arms Regulations (ITAR) requires the Agency head (NASA Administrator) to provide information security and security controls to meet the requirements of these and other Federal Laws and directives which are specified is this NPR and is applicable for all who provide, use, or have access to NASA information.

Appendix A. Terms and Definitions

Aircraft Flight Mishap. A NASA mishap occurrence associated with either:

(1) the operation of an aircraft, which takes place between the time any person boards the aircraft with the intention of flight and all such persons have disembarked, and in which any person suffers a fatality or serious injury, or in which the aircraft receives substantial damage; or

(2) the operation of an unmanned aircraft system that takes place between the time that the system is activated with the purpose of flight and the time that the system is deactivated at the conclusion of its mission, and in which any person suffers a fatality or serious injury, or in which the aircraft receives substantial damage.

Aircraft Ground Mishap. A mishap that involves an aircraft or unmanned aircraft system that does not meet the threshold of an Aircraft Flight Mishap, and in which any person suffers a fatality or serious injury, or in which the aircraft receives substantial damage.

Appointing Official. The official authorized to appoint the investigating authority for a mishap or close call, to accept the investigation of another authority, to receive endorsements and comments from endorsing officials, and to approve the mishap report.

Barrier. A physical device intervention (e.g., a guardrail) or an administrative intervention that can provide procedural separation in time and space (i.e., lock-out/tag-out procedure) that is used to reduce risk of the undesired outcome to an acceptable level.

CAP Closure Statement. A final statement made by the appointing official that documents that all corrective actions have been completed and the CAP is closed.

Cause. An event or condition that results in an effect. Anything that shapes or influences the outcome.

Center Safety Office. The Center or Headquarters safety organization responsible for reporting and recording mishaps.

Chairperson. The individual in charge of a mishap investigation board or mishap investigation team.

Close Call. An event in which there is no injury or only minor injury requiring first aid and/or no equipment or property damage, or minor equipment or property damage of less than $20,000, or not injury or only minor injury requiring first aid, but which possesses a potential to cause a mishap.

Cognizant Center Safety Office. The safety office of the Center that hosts the project or that has been assigned SMA responsibilities for the program.

Condition. Any as-found state, whether or not resulting from an event, that may have safety, health, quality, security, operational, or environmental implications.

Contributing Factor. An event or condition that may have contributed to the occurrence of an undesired outcome but, if eliminated or modified, would not by itself have prevented the occurrence.

Corrective Actions. Changes to design processes, work instructions, workmanship practices, training, inspections, tests, procedures, specifications, drawings, tools, equipment, facilities, resources, or material that result in preventing, minimizing, or limiting the potential for recurrence of a mishap.

Direct Cost of Mishap or Close Call (for the purpose of mishap classification). The sum of the 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 estimate of these costs.

Endorsing Official. The Appointing Official, Chief/OSMA, OCE, AD, CHMO, Procurement, or other official who reviews the signed mishap report and provides a signed written endorsement, comments (when applicable), and a recommendation as to whether the mishap report shall be approved or rejected.

Event. A real-time occurrence describing one discrete action, typically an error, failure, or malfunction. Examples: pipe broke, power lost, lightning struck, and person opened valve.

Event and Causal Factor Tree. A graphic representation of the mishap or close call that shows the event (accident) at the top of the tree, depicts the logical sequence of events, illustrates all causal factor(s) (including condition[s] and failed barrier[s]) necessary and sufficient for the mishap or close call occurrence, and depicts the root cause(s) at the bottom of the tree.

Executive Summary. A very top-level summary of the circumstances of a mishap that includes who, what, when, where, and why, including a description of the proximate cause(s) and root cause(s).

Ex Officio. An individual authorized to participate in all investigation proceedings and tasked to assure that the investigation is conducted in conformance with NASA policy and this NPR.

Finding. A conclusion, positive or negative, based on facts established during the investigation by the investigating authority (i.e., cause, contributing factor, and observation).

First Aid. Refer to OSHA definition in 29 CFR 1904.7.

Final Mishap Investigation Report. The signed mishap investigation report with the endorsements and comments attached.

First Responder. An individual who in the early stages of an incident is responsible for the protection and preservation of life, property, evidence, and the environment, including emergency response providers as defined in section 2 of the Homeland Security Act of 2002 (6 U.S.C. 101), as well as emergency management, public health, clinical care, public works, and other skilled support personnel (such as equipment operators) that provide immediate support services during prevention, response, and recovery operations.

Flight Hardware. Any hardware that is flown on or is a part of an aircraft, experimental flight vehicle, satellite, lighter than air vehicles, unoccupied aerial vehicle, or space transportation system.

Flight Software. Any software that is flown on or is a part of an aircraft, experimental flight vehicle, satellite, lighter than air vehicles, unoccupied aerial vehicle, or space transportation system.

High Visibility (Mishaps or Close Calls). Those particular mishaps or close calls, regardless of the amount of property damage or personnel injury, that the Administrator, Chief/OSMA, CD, ED/OHO, or the Center SMA director judges to possess a high degree of programmatic impact or public, media, or political interest including, but not limited to, mishaps and close calls that impact flight hardware, flight software, or completion of critical mission milestones.

Hull Loss. An aircraft damaged to the extent that it is not economically feasible to repair it. This includes aircraft that are destroyed and aircraft that are missing.

Human Factors Mishap Investigator. An investigator with expertise in human factors engineering and mishap causation who has the primary responsibility to assist in the collection and analysis of data, determine how human factors caused or contributed to the mishap or close call, evaluate relevant human error and determine its root cause(s), and generate recommendations that eliminate or reduce the occurrence of the error or minimize the negative effects of the error to prevent the recurrence of the mishap.

Interim Response Team. A team that arrives at the mishap scene immediately after an incident; secures the scene; documents the scene using photography, video, sketches, and debris mapping; identifies witnesses; collects written witness statements and contact information; preserves evidence; impounds evidence (at the scene and other NASA locations as needed); collects debris; implements the chain-of-custody process for the personal effects of the injured and deceased; notifies the NASA Public Affairs Officer about casualties, damages, and any potential hazards to the public and NASA personnel; advises the supervisor if drug testing should be initiated; and provides all information and evidence to the investigating authority. The team is considered "interim" because it operates as a short-term response team and concludes its mishap-response activities when the official NASA-appointed investigating authority arrives to the scene and takes control.

Intermediate Cause. An event or condition that existed before the proximate cause, directly resulted in its occurrence and, if eliminated or modified, would have prevented the proximate cause from occurring.

Investigating Authority. The individual mishap investigator, mishap investigation team, or mishap investigation board authorized to conduct an investigation for NASA. This includes the mishap investigation board chairperson, voting members, and ex officio but does not include the advisors and consultants.

Lessons Learned. The written description of knowledge or understanding that is gained by experience, whether positive (such as a successful test or mission), or negative (such as a mishap or failure).

Lost Time Injury/Illness. A nonfatal traumatic injury that causes any loss of time from work beyond the day or shift it occurred; or a nonfatal nontraumatic illness/disease that causes disability at any time.

Mishap Investigation Board (MIB). A NASA-sponsored board that:

a. Is appointed for a Type A mishap, Type B mishap, high-visibility mishap, or high-visibility close call.

b. Requires concurrence from the Chief/OSMA and the Chief Engineer on membership.

c. Consists of an odd number of Federal employees (including the chairperson) where the majority of the members are independent from the operation or activity in which the mishap occurred.

d. Has a minimum of five voting members for Type A mishaps and three voting members for Type B mishaps.

e. Includes a safety officer and a human factors mishap investigator. For all Type A mishaps involving injury, illness, or fatality, also includes an occupational health physician (or flight surgeon for aircraft-related mishaps) as a member. f. Is tasked to investigate the mishap or close call and generate the mishap report per the requirements specified in this NPR.

Mishap Investigation Team (MIT). A NASA-sponsored team that:

a. Is appointed by the CD or ED/OHO, or designee, for a Type C mishap, Type D mishap, or close call.

b. Does not require concurrence from the Chief/OSMA or the Chief Engineer on team membership.

c. Consists of an odd number of Federal employees (including the chairperson) where the majority of the members are independent from the operation or activity in which the mishap occurred. (The actual number of members is chosen at the discretion of the appointing official.)

d. Includes a safety officer and a human factors mishap investigator as members.

e. Is tasked to investigate the mishap or close call and generate the mishap report per the requirements specified in this NPR.

Mishap Investigator (MI). A Federal employee who has expertise and experience in mishap or close call investigation; has knowledge of human error analysis in mishaps; serves as the sole investigator for a Type C mishap, Type D mishap, or close call; and is tasked to investigate the mishap or close call and generate the mishap report per this NPR.

Mishap Preparedness and Contingency Plans. Pre-approved documents outlining timely organizational activities and responsibilities that must be accomplished in response to emergency, catastrophic, or potential (but not likely) events encompassing injuries, loss of life, property damage, or mission failure.

Mission Failure. A mishap of whatever intrinsic severity that prevents the achievement of the mission's minimum success criteria or minimum mission objectives as described in the mission operations report or equivalent document.

Note: A mission failure applies only to a NASA program's mission, and not a test or ongoing institutional operation. If a program accomplishes all minimum success criteria but not "full mission objectives," it is not a mission failure (even though in some cases it may appropriately be classified and investigated as a close call).

NASA Contractor or Grantee Mishap or Close Call. Any mishap or close call that a NASA contractor/grantee is required to report or investigate due to the provisions of its contract.

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

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

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

c. Occupational injury or occupational illness to NASA personnel.

d. NASA mission failure before the scheduled completion of the planned primary mission.

e. Destruction of, or damage to, NASA property except for 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 the following are true: 1) there was adequate preventative maintenance; and 2) the malfunction or failure was the only damage and the sole action is to replace or repair that component.

NASA Operation. Any activity or process that is under NASA direct control or includes major NASA involvement.

NTSB Serious Injury. Any injury resulting from an aircraft mishap in which any one or more of the following apply:

a. Requires hospitalization for more than 48 hours, commencing within 7 days from the date the injury was received.

b. Results in a fracture of any bone (except simple fractures of fingers, toes, or nose).

c. Causes severe hemorrhages or nerve, muscle, or tendon damage.

d. Involves any internal organ.

e. Involves second- or third-degree burns, or any burns affecting more than 5 percent of the body surface.

Observation. A factor, event, or circumstance identified during the investigation that did not contribute to the mishap or close call, but, if left uncorrected, has the potential to cause a mishap or increase the severity of a mishap; or a factor, event, or circumstance that is positive and should be noted.

Organizational Factor. Any operational or management structural entity that exerts control over the system at any stage in its life cycle, including, but not limited to, the system's concept development, design, fabrication, test, maintenance, operation, and disposal. Examples: resource management (budget, staff, training); policy (content, implementation, verification); and management decisions.

OSHA Final Mishap Summary. A report (OSHA 301 Form: Injury and Illness Incident Report, or an equivalent form) provided in accordance with 29 CFR 1960.70 by NASA to the Office of Federal Agency Programs for each mishap involving an OSHA recordable incident.

Permanent Total Disability. Any nonfatal injury or occupational illness that, in the opinion of competent medical authority, permanently and totally incapacitates a person to the extent that he or she cannot follow any gainful occupation and results in a medical discharge or civilian equivalent.

Permanent Partial Disability. Any injury or occupational illness that does not result in a fatality or permanent total disability, but, in the opinion of competent medical authority, results in permanent impairment through loss of use of any part of the body, with the following exceptions: loss of teeth, loss of fingernails or toenails, loss of tip of fingers or tip of toe without bone involvement, inguinal hernia (if it is repaired), disfigurements, or sprains or strains that do not cause permanent limitation of motion.

Property Damage. Damage to any type of government or civilian property, including, but not limited to, flight hardware, flight software, facilities, ground support equipment, and test equipment.

Proximate Cause. The event(s) that occurred, including any condition(s) that existed immediately before the undesired outcome, directly resulted in its occurrence and, if eliminated or modified, would have prevented the undesired outcome. Also known as the direct cause(s).

Recommendation. An action developed by the investigating authority to correct the cause or a deficiency identified during the investigation.

Responsible Organization. The organization responsible for the activity, people, or operation/program where a mishap occurs or the lowest level of organization where corrective action shall be implemented.

Root Cause. An event or condition that is an organizational factor that existed before the intermediate cause and directly resulted in its occurrence (thus indirectly it caused or contributed to the proximate cause and subsequent undesired outcome) and; if eliminated or modified, would have prevented the intermediate cause from occurring, and the undesired outcome. Typically, multiple root causes contribute to an undesired outcome.

Root Cause Analysis. A structured evaluation method that identifies the root causes for an undesired outcome and the actions adequate to prevent recurrence. Root cause analysis should continue until organizational factors have been identified or until data are exhausted.

Serious Workplace Hazard. A condition, practice, method, operation, or process that has a substantial probability that death or serious physical harm could result and the employer did not know of its existence or did not exercise reasonable diligence to control the presence of the hazard.

Substantial Damage. Damage or failure which adversely affects the structural strength, performance, or flight characteristics of the aircraft, and which would normally require major repair or replacement of the affected component. Engine failure or damage limited to an engine if only one engine fails or is damaged, bent fairings or cowling, dented skin, small punctured holes in the skin or fabric, ground damage to rotor or propeller blades, and damage to landing gear, wheels, tires, flaps, engine accessories, brakes, or wingtips are not considered "substantial damage" for the purpose of this part (from 49 CFR Part 830).

Type A Mishap. A mishap resulting in one or more of the following: (1) an occupational injury or illness resulting in a fatality or a permanent total disability, (2) a total direct cost of mission failure and property damage equal to or greater than $2 million; (3) a crewed aircraft hull loss; (4) unexpected crewed aircraft departure from controlled flight (except high performance jet/test aircraft such as F-15, F-16, F/A-18, T-38, OV-10, and T-34, when engaged in flight test activities).

Type B Mishap. A mishap that caused an occupational injury or illness that resulted in a permanent partial disability or hospitalization for inpatient care of 3 or more people within 30 workdays of the mishap, or a total direct cost of mission failure and property damage equal to or greater than $500,000 but less than $2,000,000.

Type C Mishap. A mishap resulting in a nonfatal occupational injury or illness that resulted in days away from work, not including the day or shift on which it occurred, or restricted work or transfer to another job not including the day or shift on which it occurred, or hospitalization for inpatient care of one or two people within 30 workdays of the mishap, or a total direct cost of mission failure and property damage equal to or greater than $50,000 but less than $500,000.

Type D Mishap. A mishap that caused any nonfatal OSHA recordable occupational injury and/or illness that does not meet the definition of a Type C mishap, or a total direct cost of mission failure and property damage equal to or greater than $20,000 but less than $50,000.

Witness. A person who has information, evidence, or proof about a mishap and provides his/her knowledge of the facts to the investigating authority.

Witness Statements. A verbal or written statement from a witness that describes his/her account including a description of the sequence of events, facts, conditions, and/or causes of the mishap.

Appendix B. Acronyms

Appendix C. Mishap Investigation Notional Timeline

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