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 Reaching Conclusions

Through the use of logic models, mishap causal factors and recommendations for corrective action may be categorized by area in which deficiencies exist or are suspected to exist. A suggested approach to the construction of the logic model is to select the line of reasoning to be followed, pose hypothetical causes and corrective actions which fall into the categories of causation/recommendation (e g., all potential causes which could be results of deficiencies in the person or in the machine), and test these hypothetical causes through examination of evidence.

1.2 Establishing Causes and Recommendations for Preventive Action

1.2.1 Consolidation of Findings and Recommendations - Upon completion of their investigation, group leaders should prepare group reports in the same manner and in a format compatible with that of the formal report (see Appendix H-5). These reports represent the groups' initial input to the board's report of the investigation. The group reports should be signed by all group members and should include test and contractor reports, technical analyses, and lab reports. The results of the analysis phase are reflected in the conclusions and findings of the groups. Each conclusion should be based on facts that were established during the investigations or upon the most probable causes and contributory factors if factual causes are not determined. Final determination cannot be made unless all available information has been obtained and analyzed. In some cases, conclusions may rest on best estimates pending completion of substantiating research. When time is a limiting factor, but a reasonable confidence in the outcome of the analysis exists, qualified conclusions may be submitted, subject to confirmation by subsequent research or test. Once all findings are identified, appropriate recommendations to correct the deficiencies can be made. In preparing recommendations, some of the courses for preventive action that should be considered are the development of new standards, operating procedures, design criteria, training methods, management control, motivational programs, and necessary design changes.

1.2.2 Investigation Board Concurrence - When the specialized group reports have been completed, the chairperson should assemble the investigation board in executive session. Voting and nonvoting members should be present. A recorder should be present to record the minutes of the meeting.

1.2.2.1 At this time, the chairperson should caution all present of the sensitive nature of and special handling restrictions on findings and recommendations. Security measures should be taken to protect all documents and proceedings emanating from the executive session. Board members should be reminded not to reveal the findings and recommendations of the board. The chairperson may brief the Center Director or higher authority prior to release of the report.

1.2.2.2 The chairperson may then request each group leader to submit findings and recommendations to the board (See Appendix A, Appendix H-5, and Appendix I-1 through I-4.) The voting members of the board should vote on each finding and recommendation submitted. If the vote of the board membership is equally divided, the chairperson's vote will determine the majority position. It is not unusual for groups to submit similar findings and recommendations. The board should evaluate all submissions and determine the wording to be used in the final report. The chairperson may direct a group leader to rewrite the findings/recommendations, further substantiate findings, or give further reason for rejecting other possible findings.

1.2.2.3 As each finding/recommendation is adopted, it should be identified by the recorder. Free discussion is encouraged. Often, judicious choice of wording can bring a dissenting member to agreement/concurrence with the majority. The wording of individual group findings/recommendations need not be removed from the group report. The inclusion of original statements of findings and recommendations in individual group reports provides supporting data for the board's findings and recommendations. Those findings/recommendations of specialized groups rejected by the board should not be removed from that group's report, as they may provide guidelines for improvement of overall operations.

1.2.3 Assigning Precedence and Categorizing Causal Factors - After all findings and recommendations have been discussed, their precedence (dominate root cause(s), contributory root cause(s), and significant observation(s)) should be established. Each finding should be a concise statement of fact. A finding may warrant one or more recommendations or may stand alone; the recommendations being obvious. Recommendations should follow each finding and should, if known, include a reference or recommendation as to the appropriate action organization primarily responsible for its implementation. Recommendations should be directed toward correcting the cause of the deficiencies as well as the deficiencies themselves.

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