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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1.1.1 Mishap site safety responsibilities are dependent on the type and location of the mishap. The following is representative of the type of responsibilities associated with site safety.

1.1.1.1 Mishap Investigation Board Chairperson-responsible for the conduct of all aspects of the mishap investigation including assignment of group leaders and their specific responsibilities for site safety.

1.1.1.2 Group Leaders-Responsible for dealing with specific details of the investigation:

Examples of specific types of group leaders are:

a. Materials Group Leader

b. Human Factors Group Leader

c. HAZMAT Team Group Leader

d. Emergency Response Group Leader

e. Security Group Leader

f. Other Leader types as required by the uniqueness of the mishap.

1.1.2 Personnel Safety Management in Mishap Investigations.

1.1.2.1 The unpredictable nature of mishaps implies unpredictable working conditions for personnel conducting the on-the-scene investigation. Investigators must be flexible, physically prepared, and have proven to be ready at a moment's notice to switch from an office environment to hard labor and extended hours under adverse conditions, in all extremes of climate and terrain, on all points of the globe.

1.1.2.2 The desire to get the job done expeditiously, thoroughly, and economically can easily lead to disregard for personal risks. Perseverance, dedication, and initiative have always been the hallmark of professional investigators. These are precious commodities that need to be preserved by the application of risk controls. All supervisory personnel must continuously monitor and educate to ensure risk management.

1.1.3 Physical Condition - It is difficult to remain conditioned for the rigors of fieldwork while leading a tranquil existence. The sudden transition from a sedentary life to strenuous, outdoor activity can be hazardous. Physical fitness for this type of work should be maintained.

1.1.3.1 Passing a yearly physical exam does not necessarily mean that one is in top-notch shape with regard to endurance and capability for adjustment. Do not expect to switch from an office routine to the initial demands of 12 or more hours a day in the field without suffering some ill effects or even endangering health. Performing regular moderate to vigorous exercise can lessen the deleterious effect of such a switch of endeavor. Regular exercise is beneficial for endurance, muscle tone, and overall general good health.

1.1.3.2 The investigation will probably be completed quickly and more efficiently when the chairperson sees to it that everyone on the board adheres as much as possible to a regular working day, as soon as the investigation is in hand. This not only makes for controlled expenditure and restoration of energies, but it provides the opportunity to consolidate and document the day's work and to coordinate the activities of the next day.

1.1.4 Psychological Factors - A catastrophic mishap can have a disruptive affect on the composure of those exposed to the confusion and emotions of the true disaster. One of the common defenses against the associated traumatic experiences is the irresistible urge to act, even when human lives are no longer at stake. This need for activity may seek expression without regard for endurance, personal safety, or the safety of others, and often without apparent rationale. For this reason, the greatest discretion should be used when attempting to guide the activities into proper channels. The calm and competent behavior of each board member and the firm comprehensive management of the chairperson and group leaders are required to conduct a safe, efficient, and comprehensive investigation.

1.1.5 Protective Clothing - Although it is impossible to plan for all conditions that may exist at a particular mishap site, it is expected that every investigator will arrive at the scene equipped with basic suitable gear. Preplanning to ensure that suitable generic equipment is acquired for members is essential. In extreme conditions, suitable equipment specific to the conditions may have to be acquired. This is the responsibility of the chairperson, and in some cases, is available through local military or other Federal agency sources. The logistics for and control of these supplies are the responsibility of the chairperson.

THE WEARING OF PROPER PROTECTIVE CLOTHING WHEN HANDLING WRECKAGE IS MANDATORY.

1.1.5.1 Special gloves, masks, and outer clothing shall be provided for those persons working directly with wreckage at the scene of a mishap. Hard hats shall be provided and be worn by all persons working around, in, or under wreckage.

1.1.5.2 The safety personnel and/or local officials needed in certain locales will stipulate the type of personal protection required.

1.1.6 Climate and Terrain - The quickness of the response to a call for action precludes the chance to get acclimated to conditions that vary widely from the norm. There is no need to elaborate on the health hazards associated with physical labor in extreme temperatures and altitudes. It might be important, however, to note the effects of fatigue on the safety of performance long before total exhaustion takes place. Here again is an area where human factors group leaders and supervisors must adjust the workload and hours of their personnel to the circumstances. The quality of the investigation is best served by management awareness of the need for fitness, mentally as well as physically, until the job is done.

1.1.6.1 Terrain hazards at high elevations are compounded by lower atmospheric pressure. Respiratory and circulatory problems are accentuated and can easily become critical. A briefing of all personnel involved would be most appropriate under these circumstances. In addition, it is strongly recommended to have portable oxygen and other emergency equipment available at these mishap sites.

1.1.6.2 Unexpected weather or equipment failures may isolate the investigation board in remote areas. Provisions for first aid, shelter, food, water, and fuel in such a contingency should be made before the need arises. It is recommended to use the buddy system and a method for the logging in and logging out of personnel operating in remote areas.

1.1.6.3 Proper planning and supervision can greatly help to forestall health hazards associated with extremes in terrain and climate. The greater the risks involved, the more important it is to apply restrictive and binding controls. One should not let enthusiasm and lack of discipline lead to overexertion or worse.

1.1.7 Hazards at the Site - Familiarity with the work and the hazards at a mishap site may make one overlook the lack of experience of those who assist. For this reason, it is highly desirable that the chairperson, as well as each group leader, brief all personnel on all known hazards and established safety practices. Remember that there is a shared responsibility for the safety of personnel participating in investigations.

1.1.7.1 The air transportation of certain types of hazardous materials is common. Although with appropriate measures these materials are properly protected against rough handling and moderate impact conditions, it is impossible to maintain integrity in a high-energy impact. The best protection against these hazards is timely coordination with personnel responsible for the cargo or payload manifest. When appropriate, or in case of doubt, the manufacturers of the material involved should be consulted regarding exposure hazards and protective measures.

1.1.7.2 Generally, hazardous materials are described by the following classifications:

a. Explosives.

b. Flammable gas.

c. Nonflammable compressed gas.

d. Poisonous gas.

e. Flammable and combustible liquid.

f. Flammable solid.

g. Spontaneously combustible material.

h. Dangerous when wet material.

i. Oxidizer.

j. Organic peroxide.

k. Poisonous materials (liquid or solid).

l. Infectious substance (etiologic agent).

m. Radioactive material.

n. Corrosive material (liquid or solid).

o. Composite Materials.

p. Blood-borne Pathogens.

1.1.8 Communications - Safety and coordination benefits from reliable communications between the investigation headquarters and the various scenes of activity. Short-range two-way communications can be performed adequately by use of small hand held radios. Where possible, and as soon as it is practicable, telephone communications should be established between all areas of activity. If the mishap scene is beyond short range radio range, or in an area which precludes telephone installation, long range radio equipment should be brought in by helicopter, or any other suitable means, at the earliest practicable time.

1.1.9 Safety Precautions During the Mishap Investigation - Wreckage sites can be hazardous for many reasons other than the obvious ones of possible adverse terrain and adverse climatic conditions. Personnel involved in the recovery, examination, and documentation of wreckage may be exposed to considerable physical hazards posed by such things as flammable and toxic vapors/fluids, the likelihood of injury from torn metal or falling objects, and disease. The material Group Leader assigned mishap site coordinator is responsible for wreckage security and site safety. The human factors group leader is responsible for board team member health and safety. The chairperson and the group leaders should urge everyone to exercise good judgment, utilize available protective devices and clothing, and use extreme caution when working in the wreckage.

1.1.9.1 Before anyone is allowed on site, it should be determined what hazardous materials were on the vehicle and the payload. In the event hazardous materials were identified on the flight manifest, decisions must be made regarding the type of material and the actions to be taken to either remove the material or to reduce the risk of contamination or injury. Once such a determination has been made, work at the site may start.

1.1.9.2 The wreckage in any mishap may contain blood-borne pathogens. Blood-borne pathogens are microorganisms in human blood that can cause disease in humans. They could include, but are not limited to, Hepatitis B Virus (HBV) and the Human Immunodeficiency Virus (HIV), which causes Acquired Immune Deficiency Syndrome (AIDS). These viruses do not die upon contact with oxygen, or when they dry out. Current studies, in fact, show that certain climatic conditions may prolong the infectiousness of HIV. The board chairperson should urge anyone who will work on or in the wreckage to use extreme caution concerning blood-borne viruses. At a minimum, heavy leather work gloves over nonpermeable rubber gloves are recommended when touching the wreckage. Under certain conditions, such as enclosed spaces within the wreckage where investigators may come into contact with blood or human remains, particulate or full-face masks, protective goggles, and disposable overalls and booties should be worn. Safety concerns should be promptly expressed to the respective group leader or chairperson. (Reference: OSHA Blood-borne Pathogens Standard, 29 CFR 1910.1030.)

1.1.10 Additional Safety Precautions - Exposure to hazardous materials may result in corrosive damage to body tissues, thermal injury, asphyxiation, radiation injury, disease, absorption of poisons or toxins by inhalation or through the skin, or mechanical injury (fragments from explosives or from the failure of stressed containers).

1.1.10.1 Guidance should be sought from the emergency response incident commander and safety personnel to assess the possibility of hazards to personal safety. The credentials of anyone offering information about the hazardous properties of dangerous goods involved in a mishap should be verified. Care should be taken to assure that there are not any additional threats to individual safety.

1.1.10.2 The mishap investigation shall not direct emergency response actions or activities to clean up a hazardous materials release. This is the responsibility of emergency response personnel who may take action to mitigate dangerous conditions. The need of preserving evidence should be explained to personnel directing any hazardous materials clean up and a request should be made for care to preserve evidence during cleanup activities. However, safety comes first. The mishap investigation should not become a part of the mishap.

1.1.11 Interim Mishap Response Team Transition - The mishap investigation board is responsible for taking charge of the mishap investigation upon arrival at the mishap site. The interim mishap response team should provide data pertaining to actions that have been taken prior to the arrival of the mishap investigation board, such as:

a. Initial actions taken to secure and protect the mishap scene.

b. Initial response and rescue efforts.

c. Initial mishap scene information that may be available.

d. Mishap site hazards that have been identified.

e. Any disturbance or physical movement of mishap evidence.

f. Identification of potential witnesses.
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