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This Document is Obsolete and Is No Longer Used.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 8621.1

Eff. Date: June 02, 2000

Cancellation Date: February 11, 2004

NASA Procedures and Guidelines for Mishap Reporting, Investigating, and Recordkeeping

Appendix A. Terms and Definitions

Accepted Investigation. Accepted results of an investigation conducted by another authority that may be more appropriate than a NASA investigation, such as the NTSB, the police, or other appropriate authorities.

Appointing Official. The official authorized to appoint the mishap investigation board, mishap investigator, medical board, Center-level investigation, or technical investigation team to investigate a mishap or close call, or to accept the investigation of another authority. This official is also authorized to accept the final mishap investigation report, direct the responsible organization to develop a CAP, accept the CAP, track and close corrective actions, and produce a summary report of mishap-related activities upon completion.

Approving Official. The official with the final responsibility to review and accept the NASA mishap investigation report as complete and in conformance with NASA policy.

Board Safety Advisor. An advisor or ex officio representative of the board or investigation, generally from the SMA organization, who is familiar with the investigation process and provides assistance to the Chairperson and the Appointing Official to keep the investigation process on track.

Chairperson. The NASA use of the term "Chairperson" is used to designate the individual in charge of a mishap investigation by either a mishap board or other level of investigation.

Close Call. A situation or occurrence with no injury, no damage or only minor damage (less than $1,000), but possesses the potential to cause any type mishap, or any injury, damage, or negative mission impact. (A close call is not considered a mishap, but the mishap reporting, investigation, and recordkeeping and recurrence control guidelines will be followed.)

Contributing Root Cause. A factor, event, or circumstance which led, directly or indirectly, to the dominant root cause, or which contributed to the severity of the mishap or close call. (See also Dominant Root Cause, Root Cause Analysis, and Significant Observation.)

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.

Cost of Mishap. The direct cost of replacement of damaged equipment and parts, plus labor, as well as cost of cleanup and any environmental investigation activity and restoration of property as required by Environmental regulations. In cases where replacement parts are available from salvaged or excess equipment at little or no cost to NASA, the actual cost of replacement parts may be used plus labor. The cost of the safety mishap investigation is not included.

Dominant Root Cause. Along a chain of events leading to a mishap or close call, the first causal action or failure to act that could have been controlled systemically either by policy/practice/procedure or individual adherence to policy/practice/procedure. (See also Contributing Root Cause, Root Cause Analysis, and Significant Observation.)

Ex Officio Representative. An individual authorized, due to position, to participate in all board and investigation proceedings that they deem appropriate. In NASA investigation activities, the Associate Administrator for Safety and Mission Assurance, or his/her authorized representative fulfills this role. This individual is nonvoting.

Finding. A conclusion based on facts established during the investigation by the investigating authority.

First Aid. First aid involves initial treatment and subsequent observation of work-related minor scratches, cuts, burns, splinters, etc., which (1) do not ordinarily require professional medical care even though the treatment may be provided by a physician or registered professional personnel and (2) do not involve loss of consciousness, a lost workday, restriction of work or motion, transfer to another job, or (3) do not result in payments by the Office of Workers Compensation Program. The following procedures are considered first-aid treatment.

a. Application of antiseptics during first visit to medical personnel.

b. Treatment of first degree burn(s).

c. Application of bandage(s) during any visit to medical personnel.

d. Use of elastic bandage(s) during first visit to medical personnel.

e. Removal of foreign bodies not embedded in eye if only irrigation is required.

f. Removal of foreign bodies from wound if procedure is not complicated and is, for example, by tweezers or other simple technique.

g. Use of nonprescription medications and administration of single dose of prescription medication on first visit for minor injury or discomfort.

h. Soaking therapy on initial visit to medical personnel or removal of bandages by soaking.

i. Application of hot or cold compress(es) during first visit to medical personnel.

j. Application of ointments to abrasions to prevent drying or cracking.

k. Use of whirlpool bath therapy during first visit to medical personnel.

l. Negative X-ray diagnosis.

m. Observation of injury/illness during visit to medical personnel.

High-Visibility (Mishaps or Close Calls). Those particular mishaps or close calls that possess a high degree of programmatic impact or public, media, or political interest at the judgement of the safety director.

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.

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.

Lost-time Injury/Illness. A nonfatal traumatic injury that causes any loss of time from work beyond the day or shift on which it occurred; or a nonfatal nontraumatic illness that causes loss of time from work or disability at any time. (See Recordkeeping and Reporting Guidelines for Federal Agencies, OSHA 201.4.)

Medical Treatment. The following procedures are considered medical treatment. Any NASA work-related injury/illness for which the following type of treatment was provided or should have been provided is considered to be a NASA mishap:

a. Treatment of infection.

b. Application of antiseptics during second or subsequent visits to medical personnel.

c. Treatment of second or third degree burn(s).

d. Application of sutures (stitches).

e. Application of butterfly adhesive dressing(s) or sterile strip(s) in lieu of sutures.

f. Removal of foreign bodies embedded in the eye.

g. Removal of foreign bodies from wound if procedure is complicated because of depth of impediment, size, or location.

h. Use of prescription medications (except a single dose administered on first visit for minor injury or discomfort).

i. Use of hot or cold soaking therapy during second or subsequent visit to medical personnel.

j. Application of hot or cold compress(es) during second or subsequent visit to medical personnel.

k. Cutting away dead skin (surgical debridement).

l. Application of heat therapy during second or subsequent visits to medical personnel.

m. Use of whirlpool bath therapy during second or subsequent visit to medical personnel.

n. Positive X-ray diagnosis (fractures, broken bones, etc.).

o. Admission to a hospital or equivalent medical facility for treatment (not merely observation).

Mishap Contingency Plans (Premishap Plans). Preapproved 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.

Mishap Investigator. If the Appointing Official decides that an investigation is required and it may be done by a single investigator (this could be a mishap investigation board as listed above), the Appointing Official will select a single mishap investigator. The mishap investigator will investigate the mishap using the procedures and techniques in this NPG.

Mission Failure. A mishap of whatever intrinsic severity that, in the judgment of the Enterprise Associate Administrator and 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.

NASA Contractor Mishap or Close Call. A NASA contractor mishap or close call is any accident, incident, exposure, or close call, whether or not constituting a NASA mishap or close call, which a NASA contractor is required to report or investigate due to the provisions of its contract. Contractor mishaps are categorized similarly to NASA mishaps.

NASA Mishap. An unplanned event that results in injury to non-NASA personnel caused by NASA operations; damage to public or private property (including foreign property) caused by NASA operations; occupational injury or occupational illness to NASA personnel; damage to NASA property caused by NASA operations; or mission failure. (NASA mishaps are categorized as Type A Mishaps, Type B Mishaps, Type C Mishaps, Mission Failures, or Incidents.)

NASA Mishap Investigation Board. A NASA-sponsored board, selected by the Appointing Official and consisting a group of individuals or of a single individual with expertise in the area under investigation, 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. The responsibilities of the mishap investigation board are to determine what happened, the root cause(s) of why it happened, and develop recommendations to prevent a reoccurrence. The board will provide this information to the Appointing Official in the form of a report. The mishap investigation board should also support the Appointing Official in assessment of the CAP by providing comments and/or recommendations on the proposed plan.

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

NTSB Aircraft Mishap Definition. An NTSB aircraft mishap means an occurrence associated with 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 death or serious injury, or in which the aircraft receives substantial damage.

Recommendation. An action developed by the investigation board to correct the cause or a deficiency identified during the investigation. The recommendations may be used in the preparation of the corrective action plan.

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 will be implemented.

Root Cause Analysis. The root cause analysis is a structured process for identifying the basic factors, reasons, and causes for conditions that result in mishaps or close calls. Once identified, the conditions can be corrected and future mishaps or close calls prevented. (See also Contributing Root Cause, Dominant Root Cause, and Significant Observation.)

Safety and Mission Assurance (SMA) Office of the Responsible Organization. The organization responsible for developing the record impoundment plans, familiarizing the mishap investigation board or a mishap investigator with the mishap investigation process, distributing findings and CAP's to other interested organizations, supporting the Appointing Official in his/her assessment of proposed CAP, sampling corrective action completion, and assessing effectiveness of completed corrective actions.

Significant 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, injury, or increase the severity should a mishap occur. (See also Contributing Root Cause, Dominant Root Cause, and Root Cause Analysis.)

Technical Investigation Team. When an investigation board is not required and it is determined appropriate by the Appointing Official, a technical investigation team may utilize technically knowledgeable NASA, contractor, and foreign party members outside of NASA when a joint venture mission failure or anomaly has occurred and the mishap did not result in death, injury/illness, or unanticipated damage to nongovernment property.

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.

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.

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.

Witness Statements. Witness statements include all factual statements obtained during the course of the investigation from any party providing evidence or testimony. Witness statements are considered privileged information.

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

NASA Procedures and Guidelines for Mishap Reporting, Investigating, and Recordkeeping

DISTRIBUTION: NODIS

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

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

DISTRIBUTION:
NODIS

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