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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The category of eyewitnesses in this section will be interpreted as persons in the vicinity of the mishap site at the time of the mishap. Such persons as designers, manufacturers, physicians, maintenance personnel, mechanics, metallurgists, crewmembers, and other experts in specialized fields shall not, for purposes of this section, be considered as eyewitnesses unless they observed the mishap firsthand.

NOTE: Witness statements include all factual statements obtained during the course of the investigation from any party providing evidence or testimony.

1.2 Philosophy

1.2.1 The NASA philosophy of questioning witnesses to mishaps is to interview rather than interrogate. "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 although safety investigation teams also occasionally conduct formal interviews. Even in those cases, witnesses are not sworn in.

1.2.2 "Interrogation" is considered questioning done on a formal or authoritative level such as a lawyer/witness situation, or a police officer/suspect session.

1.2.3 It is the interview rather than the interrogation philosophy which is desirable in the questioning of witnesses by mishap investigators. Witnesses shall be informed that their testimonies are to be documented and will be retained as part of the investigation report background files but will not be released as part of the investigation report. Witness shall also be informed that NASA will make every effort to keep their testimonies confidential and privileged to the greatest extent permitted by law. (See Appendix E-1) However, the ultimate decision as to whether their testimonies may be released may reside with a court or administrative body outside NASA.

1.3 Purpose

1.3.1 The investigator interviews mishap witnesses with two basic objectives in mind:

(1) To find out what the witness observed or did, (2) To find out the witness's opinion of potential causes of the mishap.

1.3.2 The thoroughness with which these two objectives are carried out is contingent upon the thoroughness of the investigator. The experienced investigator realizes that bits of seemingly insignificant information may assume great importance when combined with investigation findings in other areas.

NOTE: The following are excerpts with modifications, from Federal Railroad Administration (FRA) literature.

1.4 Locating Eye Witnesses

1.4.1 Locating mishap witnesses often requires an extensive search of the mishap site area. The following potential sources are intended as a guide in supplementing the investigator's ingenuity in locating witnesses.

1.4.2 Residents in the vicinity of the site may have information regarding time of the mishap, engine sound, duration of sound, fluctuation of dynamic level, unusual noises, local weather, relative speed, heading, initial condition of wreckage, rescue operations, etc.

1.4.3 Local authorities often will have names of witnesses.

1.4.4 Service personnel; e.g., ticket agents, dispatchers, operators, station attendants, waiters, store clerks, etc., may have valuable witness information.

1.4.5 Witnesses who believe they possess significant information often contact newspaper offices.

1.4.6 A plea, via local news media, may encourage the reticent or transient witness to contact the mishap investigation headquarters. The address and telephone number of the mishap investigation headquarters must be included.

1.4.7 Temporary area personnel such as letter carriers, delivery personnel, public utility employees, repair personnel etc., who may have been in the area at the time of the mishap may have pertinent information.

1.4.8 Expeditious arrival at the site facilitates the questioning of sightseers and the curious regarding what attracted them to the site. Those spectators may also know of other witnesses who have departed the site.

1.4.9 Rescue personnel can often provide significant occupant location or status information prior to or at the beginning of rescue operations.

1.4.10 One witness may lead to another. Ascertain whether or not the witness was alone at the time of the observation.

1.5 Witness Location Significance

1.5.1 The exact spot from which a witness makes an observation may explain differences from that of other witnesses in the mishap vicinity. A witness location chart, to be used in conjunction with the written statement, should be prepared for clarification purposes.

1.5.2 A witness downwind of a mishap may often hear sounds not audible to the upwind observer.

1.5.3 Sound is deflected and distorted by walls or buildings and may cause the witness to erroneously report direction, sound origin, or dynamic level.

1.5.4 Noise level at the point of observation may account for a witness missing significant sounds noted by other observers.

1.5.5 The witness looking toward the sun sees only a silhouette, while the witness whose back is toward the sun may note color and other details.

1.5.6 A witness located in a group may be influenced by the power of suggestion. An outspoken member of the group might exclaim, "Those two trains missed a collision by inches!" when, in fact, the lateral separation was 100 feet. The type of individual who dislikes being critical of others reports that the trains passed in close proximity when in reality the initial impression was that there was adequate separation.

1.6 Expediting the Interviewing of Witnesses

1.6.1 Prompt arrival at the mishap site is probably the investigator's finest investigation aid. It affords the opportunity of examining the wreckage before excessive disturbance, and it permits questioning of witnesses before they reflect on their observations. The investigator is urged to visit the mishap site, survey the situation, and decide upon certain questions witnesses could answer. Witnesses forget as time elapses. Association with other witnesses and other people influences them. They read newspapers, listen to the radio, and watch television, and the news media has its effect on the witness. The witness, like the fisherman, may embellish the story when listeners are less attentive than when the story was originally told. The best solution for remedying these witness frailties is to interview the witness promptly. A memory experiment associated with time lapse was conducted by a group of psychologists and revealed the following facts of significance to the witness interviewer:

1.6.1.1 Interviews taken immediately following an occurrence contained maximum detail and were generally more complete.

1.6.1.2 After a 2-day delay the information was more general with fewer specifics, but the main or more vivid points remained.

1.6.1.3 After a 7-day delay a few of the more vivid events remained but there was considerably more conjecture, analysis, and opinion injected by the witness. Witnesses, when contacted promptly, are usually appreciative of the need for mishap investigation and the promotion of safety. Some witnesses may consider the interview an imposition and become indignant and impatient when asked to recount their observations. This situation is unfortunate, but preferable to the witness who complains about the complacency of the mishap investigators who never made a contact.

1.6.2 The intelligent witness is aware of voids or blanks in the statement (which the trained interviewer realizes exists in all observations) and endeavors to eliminate them through the application of logic or reasoning. When a witness has time to reflect on the observations, there is more time to modify or supplement the facts in the interest of coherency. Maximum witness reliability can best be achieved by prompt interviewing.

1.6.3 Occasionally, subsequent evidence dictates that certain witnesses be requestioned. The requestioning of a witness does not necessarily indicate that the interviewer was remiss in the conduct of the initial interview. Instead, the investigator may employ this technique with the witness who appears to rationalize and analyze during the initial interview. The investigator would attempt to separate fact and analysis by observing whether or not the more vivid areas of observation were presented as they were initially, and whether areas of suspected conjecture and opinion were analyzed differently than when the witness was first interviewed. By this means, the investigator would attempt to separate fact and analysis and verify witness reliability. Requestioning a witness may also be in order in confirming technical group findings.

1.7 Aids to Interviewing

1.7.1 Successfully interviewing the mishap witness is primarily an application of common sense. The interviewer should show the witness the same consideration that the interviewer would appreciate if the situation were reversed. The experienced interviewer usually finds and adopts an effective style or technique in interviewing witnesses. The following suggested interviewing tips for the novice interviewer also serve as a review or checklist for the experienced mishap investigation witness interviewer.

1.7.2 During the initial narration by the witness it is advisable to take notes. The note taking should be unobtrusive, and only with the consent of the witness. Even with the consent of the witness, discretion should be used, and note taking should cease if it is distracting to the witness. Notes should not be so extensive that the witness becomes absorbed with what the interviewer is doing. Explain to the witness that the notes are used to suggest areas that may require further explanation.

1.7.3 Frequently the witness has difficulty putting into words what was observed. In cases such as this, explanatory sketches or diagrams are valuable supplements to the witness statement. They should not be construed, however, as substitutes for the narrative statement. When there is doubt concerning the exact meaning of a statement, check the answer. The simplest method is to rephrase the answer and get the witness to confirm it.

1.7.4 Courtesy and consideration should be afforded the witness at all times. Be patient if the witness has difficulty in remembering details. Normal witness observations are expected to have periodic voids. If the witness is indefinite in a given area, record the statement that way. Do not insist that the witness give a straight "yes" or "no" answer.

1.7.5 Attempt to have witnesses confine their comments to personal observations. Avoid hearsay or areas not within their personal knowledge. If a witness reports that someone else described the mishap and thus provided the information, take the name of the individual and contact the person at a later date. Get the full meaning of each statement of the witness. Analyze each answer carefully for suggestions or leads to further questions.

1.7.6 After the witness has completed the narrative, proceed with specific questions relative to areas where notes were made. Keep questions simple and avoid jargon, slang, or terminology that could be foreign to the witness.

1.7.7 Use the straightforward and frank approach in questioning the witness as opposed to the shrewd or clever techniques such as what might be used by an attorney when the witness is hostile or not cooperative. The primary purpose is obtaining information from the witness and, in most instances, not tricking or trapping the witness in an unguarded statement.

1.7.8 Avoid arguing with the witness concerning moral responsibility of the crew, operator, or public. Witnesses have been known to regard the interview as a medium for voicing their opinions on operations, noise, and other activities that annoy them. Attempt to keep the witness confined to observations relative to the mishap.

1.7.9 Do not assist the witness when there is difficulty describing some technical phase. The statement should be in the words and terms the witness understands.

1.7.10 Percentages and fractions, when used by a witness in describing an event, should be translated into exact descriptions. There is a tendency to exaggerate in terms of percentages or fractions of the whole.

1.7.11 The wording of the question is very important. The following example illustrates how answers are affected by rewording the question. "Should the United States do all in her power to promote world peace?" Of the people questioned, 9796 answered, "Yes." The question was reworded: "Should the United States become involved in plans to promote world peace?" In this instance only 6096 answered, "Yes." The connotation of the word "involved" made the difference.

1.7.12 Qualifying the witness is important in establishing observation credibility. Witness vocation and experience should be established. When a mechanic describes the sound of an engine as surging or backfiring, this observation should be more reliable than a similar observation of a person totally unfamiliar with the operations in question.

1.7.13 Use the individual versus the collective witness interview. The collective witness interview allows witnesses to hear the statements of others. In hearing these statements, witnesses could possibly take information that is mentioned by others and use this information to fill blanks in their own observations. Many times the collective witness interview will result in one witness contradicting and correcting another. In the collective witness interview, one witness may be influenced by the statement of another. Believing one of the witnesses knows more about the operation may cause others to alter details to conform with the statement of the first witness. Conformity of witness observation is not necessarily what the mishap investigator desires.

1.7.14 Use of a tape recorder is a matter of individual interviewer preference. When determining whether to use a tape recorder, the interviewer should consider the following:

a. A signed written statement from the witness is desirable.

b. The tape must be transcribed and the transcription forwarded to the witness for signature.

c. The witness must review his/her transcription and edit it for correctness .

d. Some witnesses concentrate more on the microphone than on their observations.

e. The environment may not be conducive to recording.

f. The mechanics of operating the tape recorder may be a disadvantage; e.g., changing tape in the middle of an interview, faulty recording due to an inexperienced operator, or mechanical malfunction may cause loss of information.

g. Each witness should be provided with a copy of his/her statement.

1.7.15 Courtesy is just as important in concluding the witness interview as it is in conducting it. Thank the witness for cooperating, providing the information, and preparing the signed statement; bear in mind that the statement was voluntary and, perhaps, given during the time that the witness may have allotted for something else. Provide a phone number and address where additional information can be called in or mailed if the witness recalls things to be added to the statement.

1.7.16 It is occasionally necessary to assist certain well-qualified, observant witnesses with the organization of their statements. A few minutes spent here will aid future readers in grasping the full significance of the information. Valuable witness interviews have been wasted because an investigator has failed to obtain a recorded statement in an understandable manner. Application of the following suggestions may help avoid this problem.

a. Assist the witness with the mechanics of organizing the written statement. Suggest the use of an outline if the witness appears to have difficulty in organizing the report and collecting related thoughts.

b. Encourage the witness to use drawings, sketches, or photographs if they will help clarify the written statement. Drawings, sketches, or photographs are merely supplements to the report and do not take the place of a written statement.

c. Assist the witness in organization only. Do not aid the witness with terminology; the statement should be the words of the witness.

d. Witnesses tend to minimize or omit observations that, to them, have little significance. The investigator's background should provide guidance as to the significance of the information to be included in the statement of the witness. Frequently, relatively insignificant information becomes vital to determining the cause of the mishap once the pieces of information have been put together by the experienced interviewer.

1.7.17 A witness will occasionally omit information from a written statement that was included in an oral description of the mishap. Ensure that omissions are inserted in the written report.

1.7.18 A professional approach to witness interviewing requires that the witness be provided with a copy of his/her statement. This is a common courtesy which should be afforded the witness. The copy may bring to mind additional observations the witness made relative to the mishap when there is an opportunity to leisurely reread the statement.

1.8 Analysis of Witness Observations

1.8.1 The gathering of the witness evidence comprises about 50 percent of the witness phase of the mishap investigation. The success of the witness phase hinges on the remaining 50 percent, the ability of the investigator, as an analyst, to apply technical knowledge to the seemingly unrelated observations of lay witnesses and to emerge with possible contributing and causal factors.

1.8.2 The purpose behind analyzing witness statements, as opposed to accepting them at face value, is to:

a. Translate lay person observation into possible causal factors.

b. Evolve order and logic from apparent confusion.

c. Corroborate facts by coordinating witness information and other findings.

d. Evaluate witness credibility.

e. Evaluate the witness as a potential public hearing participant.

1.8.3 Never underestimate the value of any detail in questioning a witness. A slipshod job in the witness phase may overlook a suspect area, delay finding the cause, or even mislead investigators to the extent that the cause remains undetermined.

1.8.4 In cases where there are only one or two witnesses, it is not difficult to compare statement information and correlate the information. Differences and similarities can be readily detected and isolated for further investigation. However, when the number of witnesses is large (approximately five or more) or the volume of the statements is extensive, the task becomes more difficult and the possibility of overlooking minute discrepancies increases. In those cases a simple correlation matrix, such as the one in Figure E1-1, can be a very effective tool.

1.8.5 By documenting the events and correlating them on a matrix that can be viewed in composite, the investigator can more readily see disparities and strong correlation between witness information and can identify areas where more investigation may be warranted. If a computer with data base software is available, it should be used when the number of witnesses is very large. Databases make it easier to insert events in proper sequence as they are identified. It also makes it much easier to sort and analyze for particular pieces of information. Of course, for less complex situations a pencil and piece of paper will be equally as effective. The decision is up to the investigator.
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1.9 Locating and Interviewing Witnesses-Review.

Normally, witnesses will have been identified and located prior to the investigator's arrival at the point of investigation. It is important to secure information from witnesses as soon as possible after the mishap has occurred. Statements should contain as much detailed information as possible to minimize the necessity of recalling witnesses. Extensive use should be made of voice recorders and subsequent transcriptions.

1.9.1 Witness Location - Early witness location and interview are often important in establishing details of any mishap. This appendix provides helpful information concerning techniques and aids for conducting effective interviews. Names of witnesses should be obtained by safety representatives or other personnel who arrive at the site first (after doing everything reasonable to aid the injured and prevent further damage or loss of evidence). As part of preplanning, security and safety personnel and others likely to arrive early at mishap sites should be prepared to cope with traumatic circumstances and place an appropriate priority on the importance of protecting evidence and obtaining names, addressees, and telephone numbers of witnesses. Preplanning for catastrophic mishaps should provide for designated personnel to receive periodic training in emergency and disaster assistance; i.e., evacuation, emergency assistance to victims, protection of mishap/disaster scene, threats and panic management, and collection and protection of evidence/witnesses. Instruction on the protection of hazardous areas should include factors such as toxic gas, radiation, explosives, electrical, flammables, breathing equipment, rescue equipment, and safety equipment.

1.9.2 Witness Identification - Witnesses should, for reference purposes, be identified by name, title, employer, and place of business. However, they may be given the option of not having their name published with the statement. Even so, the witnesses should be informed that their identities might have to be released in response to the courts or other requirements of law. If a witness has professional background, skill, or experience which is directly related to, or would aid in evaluating the testimony, this information should be recorded (written or voice recording).

1.9.3 Information Provided to Witnesses - Witnesses shall be informed that their testimonies are to be documented and will be retained as part of the investigation report background files and will not be released as part of the investigation report unless the testimony is particularly important to the findings or it is necessary to release the testimony in response to the courts or other requirements of law.

1.9.4 Witness Locations and Conditions - The location and conditions in which the witness viewed the events or occurrences should be entered on a witness location chart to be used in conjunction with the statement.

1.9.5 Witness Freedom to Describe - Witnesses should be allowed complete freedom in describing pertinent events relative to the mishap. Leading questions or interruptions may change the course of thought or association, causing the omission of important details.

1.9.6 Questions for Witnesses - When a witness has presented the factual evidence, specific questions should then be asked.

1.9.7 Corroboration of Testimony - Witness testimony should be corroborated whenever possible. It is advisable to interview all witnesses whose observations of the mishap were from different locations. Statements may then be compared to detect and discount inaccurate information. Statements and physical evidence at the scene of the mishap should also be correlated.

1.9.8 Privacy of Interview - Each witness should be interviewed privately since some witnesses may be influenced by the stories of others. Witnesses should be interviewed in the presence of other witnesses or supervisory personnel only if circumstances exist where it cannot be avoided.

1.9.9 Testimony Inaccuracies - Testimony by witnesses, especially those who have been injured or involved in the mishap, may contain inaccuracies. It is desirable to have verbatim transcripts of testimonies for evaluation.

1.9.10 Supplementary Statements - Witnesses should be encouraged to supplement their original statements if, upon reflection, they wish to supply additional information. Such additions, amendments, and corrections should be recorded without modifying the text of the original statement.

1.9.11 Signed Statement - It is desirable to have the witness sign the statement to verify the accuracy of the transcript. However, the witness may submit an unsigned statement or the interviewer may summarize a verbal statement.

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