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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SECTIONááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááá TITLEáááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááá PAGE

ááááááá 1áááááááá TRANSMITTAL LETTER (from board chairman to appointing official)áááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááá _____
ááááááá 2áááááááá SIGNATURE PAGE (Board Members)ááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááá _____
ááááááá 3áááááááá LIST OF MEMBERS, EX OFFICIO, ADVISORS, OBSERVERS, and OTHERSááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááá _____
ááááááá 4áááááááá EXECUTIVE SUMMARYáááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááá _____
ááááááá 5áááááááá METHOD OF INVESTIGATION, BOARD ORGANIZATION, and/or SPECIALááá CIRCUMSTANCESááááááááááááááááááááááááááááááá _____
ááááááá 6áááááááá NARRATIVE DESCRIPTION OF MISHAPáááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááá _____
ááááááá 7áááááááá DATA ANALYSISáááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááá _____
ááááááá 8áááááááá ROOT CAUSE(S), CONTRIBUTING ROOT CAUSES, SIGNIFICANT OBSERVATIONS, CAUSES (FINDINGS),
áááááááááááááááááá AND RECOMMENDATIONSááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááá _____
ááááááá 9áááááááá DEFINITION OF TERMS (if required)ááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááá _____
áááááá 10ááááááá MINORITY REPORT (if submitted)áááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááá _____

SECTIONááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááá TITLEáááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááá PAGE

ááááááá Aáááááááá MISHAP REPORT (NASA Form 1627)áááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááá _____
ááááááá Báááááááá DIRECTIVES APPOINTING BOARDáááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááá _____
ááááááá Cáááááááá OPERATING PLANS, PROCEDURES OR FLIGHT OPERATIONS PLANSáááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááá _____
ááááááá Dáááááááá MAINTENANCE AND INSPECTION RECORDSáááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááá _____
ááááááá Eáááááááá LIST OF DAMAGED PARTSáááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááá _____
ááááááá Fáááááááá PARTS TEARDOWN REPORTSááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááá _____
ááááááá Gáááááááá LABORATORY REPORTSááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááá _____
ááááááá Háááááááá PHOTOGRAPHS AND DIAGRAMSáááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááá _____
ááááááá Iáááááááá GROUP/TECHNICAL AREA REPORTSááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááá _____
ááááááá Jáááááááá CONTRACTOR REPORTSáááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááá _____
áááááá Káááááááá ADDITIONAL INFORMATIONááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááááá _____

MISHAP REPORT - VOLUME I

SECTION 1 TRANSMITTAL LETTER (from board chairman to appointing official).

SECTION 2 SIGNATURE PAGE (board members).

A signature page which denotes that the signatories certify that the information contained herein is true to the best of their knowledge. Each board member shall sign and date, the ex officio representative(s) can sign the report at their discretion. Signature of the chairperson denotes completion of the investigation and reporting process.

SECTION 3 LIST OF MEMBERS EX OFFICIO,ADVISORS, OBSERVERS, and OTHERS. (appointment letter),

SECTION 4 EXECUTIVE SUMMARY.

This section should provide a brief description of the mishap, including the extent of damage and casualties, and the major findings.

SECTION 5 METHOD OF INVESTIGATION, BOARD ORGANIZATION, and/or SPECIAL CIRCUMSTANCES.

This section should document and summarize the board organization, the structured analysis techniques used, and/or any special circumstances encountered by the board during the investigation.

SECTION 6 NARRATIVE DESCRIPTION OF MISHAP

This section should describe, in detail, the sequence of events leading up to the mishap. It should also document the actual mishap event and the events initiated as a result of the mishap occurrence, i.e., safing activities, impoundment, site preservation, management actions, etc. This section should describe what happened, who was involved, where, and when for each event in the sequence. A detailed timeline of events is recommended in this section. Detailed analysis, test reports, witness statements, and other evidence used to establish the mishap description should be attached as appendices to the report and referenced as appropriate.

SECTION 7 DATA ANALYSIS (Refer to Appendix I-1 through I-3 [I-1, I-2, I-3] for additional information).

This section should contain any analysis assumptions, the results of all analyses, and any special analysis considerations. Detailed analyses, test reports, and other evidence (except data that is contained in volume 5) used to establish the findings should be included as appropriate.

SECTION 8 FINDINGS, ROOT CAUSE(S), OBSERVATIONS, AND RECOMMENDATIONS (Refer to Appendix A for definitions, Appendix I-1 for additional information, and Appendix H-5 sample format and example).

This section lists the root cause(s) and significant observations of the mishap and why the mishap's sequence of events occurred. It should describe all of the systems configurations, personnel actions or inactions, management policies or practices (documented or not), and management actions or inaction which contributed to the occurrence of each event in the mishap's sequence of events. In order to follow this description, it is suggested that the findings map to the events in the mishap description. Redundant findings (findings which refer to more than one event in the mishap sequence) should be referenced, not repeated. For each cause there should be a recommendation provided in the report.

SECTION 9 DEFINITION OF TERMS (if required)

SECTION 10 MINORITY REPORT (if submitted)

Any information presented in the report disputed by a board member. It is helpful to specifically reference the facts or findings disputed. Detailed analyses, test reports, witness statements, and other evidence used to establish the minority facts or findings should be attached as appendices to the report and referenced as appropriate.

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