NASA Procedures and Guidelines
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NPR 8621.1 Eff. Date: June 02, 2000 Cancellation Date: February 11, 2004	NASA Procedures and Guidelines for Mishap Reporting, Investigating, and Recordkeeping
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1.1 Preserving Evidence and Controlling the Investigation Area

1.1.1 The primary concern of the investigator, upon arrival at the point of investigation, should be to assure that appropriate actions have been taken to preserve evidence, to limit access to the investigation areas, and to control the flow of technical data to the investigation board. The cognizant safety official will normally be the first representative in the investigation area and, in most cases, will have already initiated evidence preservation actions. If wreckage (used throughout as a generic term) is accessible and is to be used in the investigation, such actions should emphasize minimal physical changes to the scene due to movement and/or deterioration of wreckage until the investigators have completed their on-the-site examination. Evidence preservation actions shall not hamper essential rescue operations or the resumption of vital civil/military functions. Some specific actions that should be taken include:

1.1.1.1 Establish Liaison. Establish liaison with cognizant safety officials and security guards immediately upon arrival at the point of investigation.

1.1.1.2 Coordinate with Security. Coordinate with the Center security office or local law enforcement officials for the preparation of special orders to the guard force concerning responsibilities in the investigation area. Special orders should include instructions for entrance to areas.

1.1.1.3 Designated Classified Areas. Designate, in conjunction with Center security and Center public affairs official, areas containing classified material and/or material and subjects unsuitable for publication.

1.1.1.4 Control Access. Designate specific individuals to control access to the area (a list of personnel authorized access should be provided by the coordinating group leader or team leader).

1.1.1.5 Protect From Residual Hazardous Material. Assure protection of, or from, residual hazardous material prior to entry to the scene (specialized technical assistance may be required).

1.1.1.6 Protect Recorded Evidence. Protect recorded evidence subject to alteration. Telemetry, voice recording tapes, videotapes, and nonvolatile memory should be protected from inadvertent or intentional erasing of stored data. Checklists, logs, and other handwritten records should be impounded and/or reproduced to prevent modification.

1.1.1.7 Protect Evidence from Deterioration. Protect evidence subject to deterioration. Breaks and scratches in any metal subject to corrosion should be covered with canvas or other water-repellent material until removed to a low humidity area. Systems employing corrosive agents should be checked for leakage and possible contact with metallic objects containing evidence. Samples of materials or biological specimens should be secured for laboratory analysis.

1.1.1.8 Document Locations and Orientations. Monitor emergency groups to assure that, if possible, all items requiring removal are documented as to original location and their orientation plotted and photographed prior to removal.

1.1.1.9 Return Authority for Control. Return authority for control of the mishap scene to the program or Center officials after the requirements for investigation are met, so wreckage can be removed. The investigation Chairperson should personally approve this action.

1.2 Preservation of Physical Evidence

1.2.1 When handled in an uncontrolled manner, physical evidence may be invalidated, making it difficult to find cause. If the evidence were needed in a legal case; e.g., an employee's suit against a machine manufacturer, lost or impaired evidence would weaken the case (plaintiff or defense) and possibly embarrass the investigating organization. Therefore, it is vital that physical evidence be handled appropriately.

1.2.1.1 Identification of Evidence.

a. Tags and receipts for evidence and samples are critical and should always be used. The following is an excerpt from "Aircraft Fire Investigator's Manual," NFPA No. 422M-1972. The use of the term wreckage is meant to be generic to any mishap debris.

b. Recommended Procedures for Controlling Aircraft Parts or Chemicals Sent to Laboratories for Analysis.

c. During the course of a mishap, it may be necessary to have an analysis of a particular aircraft component, hydraulic oil, lubricating oil, or other chemicals. Specific information must accompany the sample for identification purposes, along with specific instructions to the laboratory for the type of analysis required. The following procedures must be completed before sending the sample to the laboratory.

(1) Identify each sample immediately by securely attaching a sample tag to the container.

(2) Identify the contents and, if possible, lot or batch number, when or if appropriate, and manufacturer.

(3) Identify the aircraft type, aircraft serial number, and the manufacturer.

(4) Include serial number for the sample itself. The serial number can be determined by taking the calendar year as the prefix number and assigning consecutive numbers as the samples are submitted. For example, in 1972, the first sample submitted should be 72-1 and the second 72-2 (followed by aircraft SN).

(5) Record the date the sample was taken.

(6) Note the individual who took the sample.

(7) Explain tests required in detail; i.e.,

(a) Water, sediment, etc.;

(b) Metallurgical type failure (shear, tension, heat distortion, etc.); and/or

(c) Electrical test.

d. The investigation Chairperson may designate a member of the investigation to have control of all samples that are shipped out to laboratories. Also, all analytical reports will be forwarded back through the same individual. This type of control is particularly beneficial when many samples and analyses are needed to support a mishap investigation.

1.2.1.2 Examples of Proper and Improper Evidence Collection.

a. The gathering and packaging of evidence is important to the process and should be given as much care as witness interviewing and data analysis. Following are examples of situations that helped or hindered investigations.

b. Maintenance personnel, not under the supervision of a board member or other competent professional, disassembled a failed valve. Evidence of great potential value was destroyed.

c. A semiscale heater was disassembled under the guidance of a board member using a fault tree to guide the work and avoid overlooking or destroying failure evidence. The evidence was thoroughly analyzed with no loss of information.

d. Excellent laboratory test work enabled a committee to determine the cause of an explosion, through thermal gravimetric analysis, differential thermal analysis, pyrolysis, infrared absorption spectroscopy, and gas chromatography.

e. A representative of the organization designated to receive residue for testing participated in packaging it for shipment. The sample was properly packaged and received. It yielded information valuable to the investigation.

f. Evidence was packaged improperly by an individual who was not familiar with evidence handling. The sample was contaminated and laboratory personnel were not able to discern mishap damage from packaging damage. The evidence was useless.

NOTE: The cost of analysis of physical evidence is normally born by the organization responsible for the mishap area. There may, at times, be disputes over responsibility for expenses connected with an investigation. If it is a policy that line management pays the costs of special tests and studies, the solution to this problem may be quite simple, consult the appointing authority.

g. Ways to assure field data related to physical evidence is valid:

(1) Bioassay data should be obtained by use of standard approved techniques and calibrated standards should be used for reference.

(2) Portable/stationary monitoring instrumentation readings should be validated, instruments properly calibrated and responses appropriate.

(3) Parts should be handled as little as possible if they are to be analyzed in a laboratory.

(4) Parts should be photographed before they are moved.

1.3 Failure Recognition

1.3.1 Failure analysis requires engineers/scientists who are expert in the materials involved and knowledgeable of stresses and failure modes in the specific equipment involved. Because of the great diversity of equipment used in most technical work, and because experimental equipment often approaches technological boundaries, it is not feasible to train investigators in all relevant fields. An investigator may be qualified to carry out failure analysis in a specific mishap, but in general the investigation board will rely on reliability and other engineering specialists. The objectives are as follows:

a. To define a field protocol to gather and preserve evidence of failures.

b. To increase ability to detect typical failure signs.

c. To outline some key aspects and problems in failure analysis.

1.3.2 It is essential that the investigator carefully follow a field protocol whenever failure can possibly be suspected as a causal factor. The investigator should perform the following:

a. Familiarize himself/herself with the scene of the event.

b. Begin field notes, if not started earlier. Record all possible observations (relative positions of debris, marks, fluids, and especially any anomalies).

c. Request expert assistance at the first sign of need.

d. Begin photography.

e. Begin master sketch.

f. Initiate the process of creating hypotheses and looking for positive and negative evidence.

g. Collect samples of smeared material, ash, paint, fluids, etc., as needed.

h. Initiate close-up photography of details (scratches, gouges, smears, fractures, and relative positions).

i. Tag key parts.

j. Obtain a grid map as needed.

k. Ensure evidence is thoroughly recorded before moving anything except if required for rescue operations.

l. Give responsibility of preparing evidence for transport to laboratory personnel who will do the analysis, but be sure they understand the critical nature of the material being prepared.

1.4 Identifying and Consolidating the Evidence

1.4.1 The initial efforts of the investigation board should be directed toward identifying and consolidating evidence. The investigator should refrain from drawing any conclusions until all evidence is collected and analyzed. Investigation should not be limited to data generated concurrently with, or as a result of, the mishap. It should include historical, environmental, operational, psychological, and other factors bearing on the situation. There are three general areas of investigation which should be examined. These areas are categorized as material, personnel, and records. 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. The records area includes all records and historical data associated with the specific equipment, operations, and operating personnel. As the investigation progresses, evidence should be consolidated into a form suitable for analysis. Consolidation of data provides an indication of errors, omissions, or lack of attention to a particular area so that action can be taken to obtain supplemental material or substantiating evidence before control of the investigative area and pertinent records are returned to program or functional officials.

1.4.2 Nonrecoverable Wreckage.

In most space flight mishaps, in some aircraft and ground test simulation mishaps, and in many explosive type mishaps, remotely monitored instrumentation may provide adequate information for cause factor determination. In such cases, recovering the wreckage for the purpose of investigation may prove impractical because of the costs involved, the risks taken by recovery teams, and the superior quality of evidence obtained through instrumentation recordings. The search for evidence, when the wreckage is not recovered, will normally include the readout of telemetry and voice recordings, the review of any tracking data that may be available, close attention to review of preflight or pretest records, and the viewing of video recordings. In many cases, the volume of data available, though extremely helpful, may be too large to properly examine without a systematic approach. The recommended technique is to review video and voice recordings, first to arrive at the suspected failure and/or times of failure; and second, to examine telemetry data from associated equipment during the suspected time of failure. Observations of hardware operational parameters are usually available from two sources for manned systems (1) on team instruments monitored by the crew with measurements transmitted to controllers via voice communications links, and (2) data monitored on team assignments and transmitted to controllers via telemetry links. Instrument panel readouts and switch positions may be determined directly from video transmissions. Comparisons of data from various modes of transmission should be made to substantiate evidence. Without telemetry instrumentation, it will be necessary to rely heavily on the observations of witnesses and/or voice recordings with supplemental information from equipment and personnel historical data. For nontest and most normal operations mishaps, such sophisticated information gathering is not available and the investigator must rely on witness statements, physical evidence, and analysis to find out what happened.

1.4.3 Recoverable Wreckage.

When the mishap scene is accessible and the wreckage is to be recovered for analysis, there are certain steps that should be taken to maximize the effectiveness of efforts to locate and consolidate evidence. Removal of wreckage should be prevented until all significant evidence has been gathered and everything possible has been learned from the wreckage scene. When necessary to remove wreckage promptly, so as to not hamper rescue operations or to permit resumption of vital civil or military functions, each significant piece should be identified and marked as to original location and handled with care to avoid additional damage. Release of parts for salvage or detailed inspection at another location should be controlled by the coordinating group in conjunction with the investigation board leader. These steps include a preliminary survey of the mishap scene, a review of records, an examination of witness testimony, a reconstruction of the wreckage, and an examination of the recovered parts.

a. Preliminary Survey: A preliminary survey of the mishap site during which the relative positions of parts or debris can be studied will aid in establishing the nature of the mishap. Physical examination and recording of evidence at the scene will enable the investigator to reach and support conclusions as to what caused the mishap. This survey is accomplished by:

(1) Interviewing on-scene witnesses.

(2) Diagramming the mishap area to scale and indicating relative positions of equipment, wreckage, bodies, obstructions, flight path (if applicable), positions of witnesses, etc. Several methods may be used in plotting the area diagram. The choice depends mostly upon terrain. These methods are as follows:

b. Grid. The grid consists of equal size squares, the scale and size of which depends upon extent of wreckage scatter. Grid lines should be laid off on ordinal compass headings, using surveyor's equipment or a compass and tape. (Overlay or circular grid over square grid is useful in explosive mishaps where a radial pattern of debris may be expected.)

c. Distance and Heading. This method consists of plotting significant wreckage parts by distance and degrees from a central or initial point, normally the impact point. The presentation will be basically the same as the grid system but will require a full time surveyor and may consume more time.

d. Vertical Photographs. Aerial photographs can be used to advantage where wreckage is scattered over a great distance or where extreme terrain problems exist. This type of vertical photograph is especially adaptable in early coverage of a mishap involving hazardous material contamination.

e. Layout Plans or Photography. When mishaps occur in areas for which drawings are available or where helicopter coverage is most convenient, it is preferred that wreckage plotting be accomplished on layout plans or with the aid of close range aerial photographs. Three dimensional (perspective) drawings, cutaway drawings, and schematics may be useful for plotting areas where depth cannot be shown by vertical drawings, maps, or photographs.

1.4.3.1 Photographing the mishap scene, wreckage, and pertinent hardware should be made prior to removal or disturbance. Such information is helpful in determining what happened as well as providing illustrations for reports. In instances where unusual wreckage patterns exist or where there is evidence of in-flight collision, color photographs are of value. This is especially true when differentiating between smoke or oil discolorations and between various colored paint smudges which would appear black in conventional photographs. Stereoscopic photographs of bodies and detailed parts may be useful in the investigation. When applicable, the location of the photographers and the angle/direction from which the photograph was taken should be noted. Official photographs, whenever available, should be used as admissible evidence and contained in the report. However, press photographs or others may be useful and necessary if the subject or object has not been covered in official photographs.

1.4.3.2 Recovering all parts of the equipment, materials, vehicle, or system. It is sometimes necessary to search far back along the flight path and in surrounding localities for parts, debris, and clues in an aircraft mishap. Aerial photographs may be used to point out exact locations or to provide clues as to where to search for portions of the wreckage. Members of the investigation board should be available to observe or to supervise recovery operations. When water is included in the mishap scene, the problem of locating and recovering parts becomes more complicated. Special services and equipment may be required. This support can be obtained through official contact with the United States Navy and/or Coast Guard or by local commercial salvage companies. The problem of location can often be solved by plotting the crash site from descriptions of witnesses or from radar ground plots. Another indication could be air bubbles which may appear for several days after the mishap. A third method is dragging the area and/or using sonar. Minesweeping activities have special equipment designed for the location of objects under water. When the wreckage is located, divers or submersibles may be used to locate parts. Underwater photography may be used as an effective investigative technique for recording the relative position of parts. It should be remembered that salvage personnel may not have experience with aerospace vehicles and the investigators should provide all possible assistance. A vehicle striking the water often suffers not only the damage of impact but the additional hydraulic effect of water entering and exerting an outward force. Thus, the wreckage scatter pattern and the structural or component failure patterns may be unlike that experienced with ground impact. When investigating water mishaps, consideration should be given to the effect of tide on the dispersal of wreckage. Appropriate members of the investigation board should be available to supervise recovery operations and to determine the extent of recovery. Photographs should be obtained of recovered parts. Drawings of part location and general condition may be required. The damage inflicted during recovery should be properly noted to minimize confusion during subsequent detailed analysis. The wreckage parts should be flushed with fresh water to reduce the effect of salt water corrosion. Parts destined for detailed inspection should be provided to the inspection agency as soon as possible to minimize the effects of corrosion. The recovery phase should be video taped to identify any damage resulting from the recovery operations.

1.4.3.3 Tagging of parts must be accomplished as the parts are recovered. Tags should identify the system and component nomenclature of the part. When tagging parts, the investigator should:

a. Tag and identify all parts and wreckage which may contribute to the investigation and enter the information in a log. All parts should be tagged and numbered both on the tag and in a recovered parts log.

b. Draw on the tag a sketch showing the location of the recovered part relative to the grid lines (if the grid system is used) or the center point (if the distance and heading method is used).

NOTE: It is suggested that the top of the tag, as it is set in the reading position, be established as North to reduce the possibility of misinterpreting the geographical position of parts.

c. Note on the tag the nomenclature of the part and its suspected relationship to the cause of the mishap. Tags on parts which cannot be definitely identified should contain a list of possibilities as to their nomenclature, or if suspected of being foreign to the system or vehicle in question, and their possible source. The investigator should not tag parts which obviously have no significance to the investigation.

d. Assign numbers to all parts if pieces are numerous and widely dispersed, and note the applicable number on both the tag and the area diagram or area photograph.

e. Print the investigator's name legibly on the tag.

f. Have each tagged part recorded for individual use and the use of the group. A compilation of recorded parts will establish what parts have been identified and will thus aid the search for parts still missing.

1.4.3.4 Preservation of parts, subassemblies, or major components suspected of failure, malfunction, or faulty design should be accomplished immediately after photographs are made, relative positions are determined, and tagging is complete. Before removal for tests or disassembly, all such parts should be wrapped or boxed to prevent further damage. Examples of parts which should be preserved are:

a. Parts suspected of initial failure, improper heat treatment, or improper material specification.

b. Lines, fittings, wiring, mechanical controls, and explosive devices not properly attached and subject to excessive vibration.

c. Ruptured plumbing or fittings.

d. Power supply components or communication equipment suspected of being faulty.

e. Instruments suspected of being faulty.

f. Defective engines and accessories.

g. Hydraulic actuators.

h. Survival gear.

i. Control systems.

1.4.4 Laboratory Analysis

There is a wide array of laboratories available to perform specialized analyses for the investigator. The availability and cost are determined by the type of analysis and the accessibility of the laboratory to the investigator. For instance, NASA has widely distributed personnel and facilities for failure analysis. Thus, the investigator's task is to recognize signs of failures and to know where and how to get analytic assistance. The NTSB and the Department of Transportation have metallurgical laboratories and collections of parts exhibiting various modes of failure. NTSB reports also reflect increasing reliance on tests and analyses performed by the National Bureau of Standards. There are also commercial laboratories available to accomplish many types of testing.

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