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
| TOC | ChangeHistory | Preface | Chp1 | Chp2 | Chp3 | Chp4 | Chp5 | Chp6 | All-Appendices | AppdxA | AppdxB-All | AppdxB1 | AppdxB2 | AppdxB3 | AppdxB4 | AppdxC | AppdxD | AppdxE-All | AppdxE1 | AppdxE2 | AppdxF-All | AppdxF1 | AppdxF2 | AppdxF3 | AppdxG | AppdxH-All | AppdxH1 | AppdxH2 | AppdxH21 | AppdxH3 | AppdxH4 | AppdxH5 | AppdxH6 | AppdxH7 | AppdxI-All | AppdxI1 | AppdxI2 | AppdxI3-All | AppdxI31 | AppdxI32 | AppdxI33 | AppdxI34 | AppdxI35 | AppdxJ-All | AppdxJ1 | AppdxJ2 | AppdxJ3 | AppdxJ4 | AppdxJ5 | AppdxJ6 | AppdxJ7 | AppdxJ8 | AppdxJ9 | AppdxJ10 | AppdxJ11 | AppdxK | AppdxL | AppdxM | Cover | ALL |

1.        Determine Initial Assessment of Mishap Situation ..............................................................................................................................................____
           a)        Status
                      i)    Is it Safe?
                      ii)   Is Area/Evidence Controlled?

2.        Assess Team ...................................................................................................................................................................................................____
           a)        Technical Expertise/Gaps
           b)        Management Experience & Knowledge
           c)        Analytical Technique Expertise
           d)        Independence
           e)        Personalities
           f)        Availability

3.        Modify Board? Form Subteams (If Necessary) ................................................................................................................................................____

4.        Identify Consultants/Specialists (If Necessary) .................................................................................................................................................____

5.        Establish Board Organization/Management/Administrative Process ...................................................................................................................____
           a)        Reporting
           b)        Regular Meetings
           c)        Investigate Together/Separate
           d)        Schedules
           e)        Etc.

6.        Identify Additional Information Needs ..............................................................................................................................................................____
           a)        Witness Interviews (See E-2)
           b)        Data/Data Analysis
           c)        Hardware/Hardware Analysis
           d)        Configuration Audits
           e)        Policy Documents

7.        Select Systematic Methods for Investigation .....................................................................................................................................................____
           a)        Determine Immediate Cause/Sequence (Hardware, Software, Environmental Factors, Operator Error, Interactions)
                      i)         Fault Tree
                      ii)        Event Tree
                      iii)       Events and Causal Factors Timeline (Chronological)
                      iv)       Energy Trace and Barrier Analysis

9.        Form Conclusions ............................................................................................................................................................................................____
           a)       System, Personnel, Management Deficiencies
           b)      Conclusions must be consistent with all the data
           c)      Try to prove conclusion via simulation test (if necessary and feasible)

10.        Develop Recommendations ............................................................................................................................................................................____
             a)       Address Both Immediate Causes and Root Cause(s)
             b)      Clearly State Intended Action
             c)      Ensure Recommendations are Practical, Feasible, and Achievable
                      i)         May Provide Prioritized Options for Management Decision
             d)      Ensure Recommendations are Specific Enough, but not too Specific (Allow for Optimization by Affected Organization)
             e)      Include Target Completion Date (Possibly Interim Dates for Phased Implementation)
             f)       Include Person/Organization Responsible for Implementation
                      i)        Supporting Responsibilities
                      ii)       Monitoring & Tracking Responsibilities
             g)      Coordinate with Affected Organizations prior to release
                      i)       Technical Assistance/Sanity Check
                      ii)      Buy-In

11.        Monitor and Track to Completion ...................................................................................................................................................................____
             a)     Immediate/Time Sensitive Actions
             b)     Long-Term Actions

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