Responsible Office: QS

Subject: NASA Mishap Reporting and Investigating Policy

1. POLICY

It is NASA Policy to perform the following: 

a. Report, investigate, and document NASA mishaps.

b. Use information from the NASA mishap investigation process as a key
element of NASA`s mishap prevention program.  The results of mishap
investigations will not be used in matters related to civil, criminal, or
administrative culpability or liability, or for disciplinary actions.

c. Maintain contingency plans at each appropriate organizational level to
insure effective response to NASA mishaps, life threatening emergencies,
or natural or human-made disasters in order to mitigate further injury to
personnel, or additional damage to, or loss of, equipment or property.
 
d. Secure, safeguard, and impound evidence relating to a NASA mishap until
released by an officially sanctioned NASA Mishap Investigation Board (MIB).

e. Conduct NASA mishap investigations, using NASA MIB's, with properly
trained personel.

f. Determine the cause(s) of NASA mishaps in order to develop and implement
corrective actions that reduce the probability of mishaps' recurrence.

g. Develop and report corrective actions and lessons learned, utilize
lessons learned in NASA operations, and exchange lessons learned and other
pertinent safety information of common interest with other Federal agencies,
NASA contractors, and international partners.

h. Consider witness statements given in the course of a NASA mishap
investigation as privileged and nonreleasable.  NASA may also withhold
other information in a NASA mishap investigation report from release,
depending on such factors as to whether such information is classified,
privileged, or involves privacy considerations.  NASA recognizes that the
ultimate decision on release of statements or information in a NASA mishap
investigation report may reside in a court or administrative body outside
NASA.

i. Make prompt release to the news media and the public of factural
information concerning NASA mishaps resulting in serious injury or death
to persons(s), or extensive damage to or destruction of property, and make
timely release of information from NASA mishap investigation reports, as
appropriate.

j. Support investigations of NASA mishaps by other Federal agencies that
have authority to investigate NASA mishaps (such as the National Transportation
Safety Board (NTSB) for aircraft mishaps and Department of Labor for
occupational mishaps).  Support investigations of mishaps experienced by
other Federal agencies, foreign governments, and private industry in
accordance with agreements.

k. Ensure that agreements for programs involving international partners
or other Federal agencies incorporate elements of this NPD, as
appropriate.

2. APPLICABILITY

a. This NPD is applicable to NASA Headquarters, NASA Centers, including
Component Facilities, JPL, and other NASA contractors to the extent
specified in their contracts.

b. The following definitions shall apply to this NPD:

(1) NASA Mishap - Any unplanned occurrence or event resulting from any NASA
operation or NASA equipment anomaly, involving injury or death to persons,
damage to or loss of property or equipment, or mission failure, provided
that a written agreement or contract between NASA and another party did not
otherwise allocate operational control and corrective action responsibility.
NASA mishaps are categorized as follows:

(a) Type A Mishap - A mishap causing death and/or damage to equipment or
property equal to or greater than $1 million.  Mishaps resulting in damage
to aircraft, space hardware, or ground support equipment that meet these
criteria are included, as are test failures in which the damage was
unexpected or unanticipated.

(b) Type B Mishap - A mishap resulting in permanent disability to one or
more persons, hospitalization (within a 30-day period from the same mishap)
of three or more persons, and/or damage to equipment, or property equal
to or greater than $250,000, but less than $1 million.  Mishaps resulting in
damage to aircraft, space hardware, or ground support equipment that meet
these criteria are included, as are test failures in which the damage was
unexpected or unanticipated.

(c) Type C Mishap - A mishap resulting in damage to equipment or property
equal to or greater than $25,000, but less than $250,000, and/or causing
occupational injury or illness that results in a lost workday case.  Mishaps
resulting in damage to aircraft, space hardware, or ground support equipment
that meet these criteria are included, as are test failures in which the
damage was unexpected or unanticipated.

(d) Mission Failure - A mishap of whatever intrinsic severity that,
in the judgment of the Enterprise Associate Administrator/Institutional
Program Officer, in coordination with the Associate Administrator for
Safety and Mission Assurance, prevents the achievement of primary NASA
mission objectives as described in the Mission Operations Report or
equivalent document.

(e) Incident - A mishap consisting of personal injury of less than Type C
Mishap severity but more than first-aid severity, and/or property damage
equal to or greater than $1,000, but less than $25,000.

(f) Close Call - An occurrence in which there is no injury, no equipment/property
damage equal to or greater than $1,000, and no significant interruption of
productive work, but which possesses a high severity potential for any
of the mishaps defined as Types A, B, or C Mishaps, Mission Failure, or
Incident.

(2) Appointing Official - The official with the responsibility to perform
the following: a) Determine the level of investigation, the type of investigation,
and the NASA MIB membership; b) Accept the initial NASA MIB report as fulfilling
the requirements of the investigation; and c) Ensure closure of approved
corrective actions.

(3) Approving Official - The official with the final responsibility to
review and accept the NASA MIB report as complete and in conformance with
NASA policy.

(4) NASA Operation - Any activity or process under the direct control
of NASA.

(5) NASA Mishap Investigation Board - A NASA-sponsored board, consisting
of a single individual or a group of individuals with expertise in the area
under investigation which is appointed to investigate a NASA Mishap. Board
members must not have any vested interest in the outcome of the investigation.
Board members may be selected from NASA, or other Government agencies.
Observers may be obtained from these same sources or from non-Government
sources, such as consultants.  For international programs, board members will be
appointed as provided in negotiated agreements.

(6) 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.

(7) Lessons Learned - Knowledge or understanding gained by experience.
The experience may be positive, as in a successful test or mission, or
negative, as in a mishap or failure.  A lesson must be significant in that
it has real or assumed impact on operations; valid in that it is factually
and technically correct; and applicable in that it identifies a specific
design, process, or decision that reduces or limits the potential for failures
and mishaps, or reinforces a positive result.

3. AUTHORITY

a. 42 U.S.C. 2473(c)(1), Section 203(c)(1), the National Aeronautics
and Space Act of 1958, as amended.

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

c. Executive Order 12196, dated February 26, 1980, "Occupational Safety
and Health Programs for Federal Employees," 3 CFR (1980 Compilation).

d. 29 CFR Part 1960, "Basic Program Elements for Federal Employee
Occupational Safety and Health Programs and Related Matters."
 

4. REFERENCES

a. NPD 8700.1, "NASA Policy for Safety and Mission Success."

b. NPD 8710.2B, "NASA Safety and Health Program Policy."

c. NPG 8715.x, "NASA Safety Manual."

d. NPG 8715.x, "Guidelines for Mishap Reporting, Investigating, and
Recordkeeping."

e. 49 U.S.C. 1131-1135, Authority of the NTSB to conduct investigation of
public aircraft accidents. 

f. 49 CFR Part 830, "Notification and Reporting of Aircraft Accidents or
Incidents and Overdue Aircraft, and Preservation of Aircraft Wreckage, Mail,
Cargo, and Records;" Part 831, "Accident/Incident Investigation Procedures"
(NTSB).

g. 41 CFR Subpart 101-37.11, "Accident and Incident Reporting and Investigation"
(Federal Property Management Regulations).
 

5. RESPONSIBILITY

a. The Associate Administrator for Safety and Mission Assurance is
responsible for the following:

(1) Ensuring that the NASA Lessons Learned Information System data base is
maintained and accessible for the collection, retention, and retrieval of
lessons learned.

(2) Serving as the Appointing Official and the Approving Official for NASA
MIB's directed by the Administrator, or for those high visibility NASA
Mishaps, including high-visibility mission failures, or high-visibility close
calls, which he or she may select.

(3) Concurring in the membership of any Enterprise-appointed NASA MIB
and serving as the Approving Official for its report.  The Associate
Administrator may participate or may designate a NASA official to
serve as an ex officio member of any NASA MIB`s.

(4) Providing a qualified NASA official to support NTSB investigations
of NASA aircraft mishaps.

(5) Dispositioning approved NASA MIB reports and related documents per NASA
records management policy.

(6) Providing mishap information to NASA personnel, other Government agencies,
and international entities in accordance with established requirements or
mutual agreements, and facilitating the communication of general lessons
learned information that is derived from mishap investigations.

(7) Defining mishap investigation training requirements for NASA personnel.

b. The Associate Administrator for Public Affairs is responsible for
releasing NASA mishap information and, in selected circumstances, other types
of mishap information impacting upon NASA, in coordination with the
Headquarters Safety and Risk Management Division, and the NASA Office of
the General Counsel, pursuant to NASA procedures.

c. Enterprise Associate Administrators/Institutional Program Officers are
responsible for the following:

(1) Ensuring that their program policy and supporting documents implement
the requirements of this NPD.

(2) Developing agreements for joint programs with international partners
and other Federal agencies that incorporate elements of this NPD to ensure
that joint mishap investigating and reporting fulfills NASA policy and
procedures.

(3) Notifying the Office of Safety and Mission Assurance of any Type A 
Mishap or Type B Mishap, any high visibility mission failure, or any high
visibility close call.

(4) Determining, in coordination with the Associate Administrator for
Safety and Mission Assurance, that an unplanned occurrence or event
constitutes a mission failure because it prevents the achievement of
primary mission objectives as described in the Mission Operations Report
or equivalent document.
 
(5) Serving as the Appointing Official for investigations of Type A or
other high visibility NASA mishaps, including high-visibility mission
failures, or high-visibility close calls, except those referenced in
paragraph 5.a.(2) above.

(6) Ensuring the development and aggressive implementation of corrective
actions to reduce the probability of recurrence of mishaps within their
Enterprise, NASA Centers, and Component Facilities.

(7) Contributing to and utilizing the NASA centralized lessons-learned
information system as a key element of the mishap prevention program.
Specific attention should be paid to lessons learned, relative to program/project
management processes.

(8) Preparing and briefing the NASA Administrator and other appropriate
senior managers of NASA MIB results for any Type A Mishap, or any other
NASA mishap selected by the Administrator, or the Associate Administrator
for Safety and Mission Assurance.

d. The Directors of NASA Centers and the NASA Headquarters Associate
Administrator for Center Operations are responsible for the following:

(1) Utilizing the NASA Lessons-Learned Information System for documenting,
investigating, and applying lessons learned, as applicable, to all
programs and projects as a key element of the mishap prevention program.

(2) Establishing Center-specific procedures that implement the requirements
of this NPD, including procedures for releasing NASA mishap information and,
in selected circumstances, other types of mishap information impacting upon
NASA, by the Center Public Affairs Office in coordination with the Center
Safety and Mission Assurance Functional Manager and the Center Office of
the Chief Counsel.

(3) Ensuring that contingency plans are in place to properly secure the
mishap site, impound evidence, and provide necessary notification to the
program and other Agency organizations.

(4) Taking immediate action following a NASA mishap to limit further
damage or injury.

(5) Notifying the Office of Safety and Mission Assurance of any Type A Mishap
or Type B Mishap, any high-visibility mission failure, or high-visibility
close call.

(6) Serving as the Appointing Official and the Approving Official for
investigations of Type B Mishaps or other NASA mishaps solely within their
purview.
 

6. DELEGATION OF AUTHORITY

None.

7. MEASUREMENTS

Conformance to the requirements of this NPD will be measured by the
following:

a. Promptness and thoroughness of responses to, reporting of, and investigation
of NASA mishaps.

b. Quality of lessons learned and reporting data covering NASA mishaps.

c. Effectiveness of corrective actions to reduce the potential for
recurrence of NASA mishaps.

d. Quality and completeness of implementing the mishap reporting program
and Agency policy requirements within the respective NASA organization.

e. Contribution to, and utilization of, the NASA Lessons-Learned Information
System in all programs, projects, and operational activities.
 

8. CANCELLATION

NMI 8621.1F, dated December 31, 1991. 

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/s/ Daniel S. Goldin
Administrator

ATTACHMENT A: (TEXT)

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