NASA Procedures and Guidelines
This Document is Obsolete and Is No Longer Used. Check the NODIS Library to access the current version: http://nodis3.gsfc.nasa.gov
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 |

1.1 NASA Administrator

The NASA Administrator can elect to be the Appointing Official for Type A mishap investigations. (See Appendix A for definitions of mishap types.) In such instances, the Associate Administrator for Safety and Mission Assurance will provide assistance and support in board appointment activities and in the investigation, approval, and corrective action process.

1.2 Associate Administrator for Safety and Mission Assurance

1.2.1 The Associate Administrator for Safety and Mission Assurance (or designee) is responsible for the following:

a. Assuring the proper reporting, investigating, and recordkeeping for mishaps and close calls by defining and administering the mishap reporting and investigating process.

b. Concurring with the assignment of responsibility for conducting the investigation and membership for Type A mishaps or high-visibility mishaps or close calls. The Associate Administrator for Safety and Mission Assurance may grant authority to the Space Shuttle and International Space Station programs to conduct program level technical investigations instead of a higher level investigation board for certain anomalies or close calls (see Chapter 3).

c. Approving the mishap investigation board membership and level and serving as the Approving Official for the mishap investigation board report generated by any investigation appointed by an Enterprise Associate Administrator or the Associate Administrator for Headquarters Operations (Type A only).

d. Providing assistance to the Appointing Official in reviewing Corrective Action Plans (CAP's).

e. Participating, at his/her discretion, as an ex officio representative (or designating an individual to participate on his or her behalf) in any NASA mishap investigation board or investigation activity to the level deemed appropriate to either assist the conduct of the investigation or to monitor the mishap investigation activities to ensure that activities are thorough, impartial, and in conformance with NASA policy.

f. Serving as the Appointing Official and Approving Official for mishap investigations directed by the Administrator or for those high-visibility mishaps, mission failures, or close calls that the Administrator may select. (See NPD 8621.1 , "NASA Mishap Reporting and Investigating Policy.")

g. Notifying the Occupational Safety and Health Administration (OSHA) Office of Federal Agency Programs of the mishaps listed in paragraph 2.3.2 and forwarding to OSHA's Office of Federal Agency Programs a final copy of the mishap summary of any mishap for which notification was made.

h. Notifying the National Transportation Safety Board (NTSB) of any incidents listed in paragraph 2.3.3 and negotiating NTSB's involvement, if any, in investigations or other followup activities.

1.2.2 The Associate Administrator for Safety and Mission Assurance will serve as Appointing Official for NASA joint participation on boards with the Department of Defense (DoD) and other agencies unless authority is delegated by existing agreements.

1.3 Enterprise Associate Administrators

The Enterprise Associate Administrators are responsible for the following:

1.3.1 Enterprise Associate Administrators have primary responsibility for implementing mishap reporting, investigating, and recordkeeping requirements for their assigned Enterprises.

1.3.2 The Enterprise Associate Administrator will be the Appointing Official for Type A mishaps, or high-visibility close calls, mission failures, or other mishaps (after consulting and receiving agreement from the Administrator or the Associate Administrator for Safety and Mission Assurance to determine if they desire to be the Appointing Official). The Enterprise Associate Administrator may delegate this authority only after consulting with and receiving agreement from the Associate Administrator for Safety and Mission Assurance.

1.3.3 The Enterprise Associate Administrator will obtain concurrence from the Associate Administrator for Safety and Mission Assurance on mishap investigation board levels and proposed membership.

1.3.4 The Enterprise Associate Administrator will develop mishap contingency plans (premishap plans, procedures, and activities) to support this NPG.

1.4 Associate Administrator for Headquarters Operations

The Associate Administrator for Headquarters Operations is responsible for the following:

a. Serving as the Appointing Official for Type A mishaps and lesser mishaps and close calls that occur at NASA Headquarters, with the advice of the supporting safety official, and serving as the Approving Official for investigations below Type A.

b. Developing NASA Headquarters-level mishap contingency plans (premishap plans, procedures, and activities) to support this NPG.

c. Developing and documenting a reporting, investigation, and prevention process that meets the NASA Headquarters data collection and analysis needs, and as a minimum, identifies the what, where, when, and why of the mishap or close call. Additionally, the Associate Administrator for Headquarters Operations should dictate the local timelines for initial notification of the mishap, finalization of the mishap report, and generation of the CAP to meet the requirements of this NPG.

d. Ensuring the final mishap information is documented in a mishap report and submitted in accordance with this NPG.

e. Providing administrative and logistical support for investigation boards working at NASA Headquarters.

1.5 NASA Center Directors

Each NASA Center Director is responsible for the following:

a. Serving as the Appointing Official for Type B mishaps (and Type A when delegated), and lesser mishap or close call investigations to determine their cause.

b. Developing Center-level mishap contingency plans (premishap plans, procedures, and activities) to support this NPG.

c. Developing and documenting a reporting, investigation, and prevention process that follows this NPG, meets their individual Center's data collection and analysis needs, and as a minimum, identifies the what, where, when, and why of the mishap or close call. Additionally, each Center should dictate the local timelines for initial notification of the mishap, the mishap report, and the CAP to meet the requirements of this NPG.

d. Ensuring the final mishap information is documented in a mishap report and submitted to NASA Headquarters in accordance with this NPG.

e. Providing administrative and logistical support for investigation boards working on the Center.

1.6 Program/Project Managers

1.6.1 Program/project managers will serve as the Appointing Official for Type A or B mishap boards (when delegated), lesser investigation activities or close calls, or special program level technical reviews to determine the cause of a failure, with the advice of the program safety official.

1.6.2 When experiencing a mishap involving hardware or facilities within their program jurisdiction, program/project managers will provide funding/support for investigations chartered by the Administrator, the Associate Administrator for Safety and Mission Assurance, or the Center Director.

1.6.3 Program/project managers will develop program/project level mishap contingency plans (premishap plans, procedures, and activities) to support this NPG. For NASA programs and projects involving international partners, program/project managers will address the responsibilities and procedures for mishap investigation in the bilateral or multilateral agreements.

1.6.4 Program/project managers will provide support to Appointing Officials in monitoring and assessing the status of corrective action plan implementation.

1.7 NASA Center Safety and Mission Assurance Officials (including Safety Officials)

1.7.1 In the event of a NASA mishap, NASA Center safety and mission assurance officials will perform the following, after first assuring that emergency response actions have begun:

a. Notify NASA Headquarters (the Safety and Risk Management Division of the Office of Safety and Mission Assurance) within 1 hour by telephone, facsimile, or electronic mail during normal duty hours, or the NASA Headquarters Emergency Center (Security Desk), 1-866-230-NASA (1-866-230-6272), during nonduty hours, of all mishaps and close calls requiring immediate notification (see Chapter 2 ). Telephonic reports must be followed up with an electronic report within 1 hour.

b. After initial notification to NASA Headquarters (if required) and to other appropriate Center personnel, such as the Center Public Affairs Office (PAO), submit an electronic transmission through the Incident Reporting Information System (IRIS) on NASA Form (NF)-1627A, "Initial Safety Incident Report," to the NASA Safety and Risk Management Division (see Appendix F) by COB of the next workday.

c. Provide the OSHA area office nearest the site of the mishap (or call OSHA at 1-800-321-6742) and the Safety and Risk Management Division with the information described in Chapter 2 within 8 hours of work-related accidents involving the death of a Federal employee, or the hospitalization of three or more employees (provided at least one is a Federal employee). This is required for any fatality or three or more hospitalizations that occur up to 30 days after the respective mishap. The NASA Center safety and mission assurance official must persist in making this report until an acknowledgement has been received. The official will provide two copies of a summary report, as required by 29 CFR 1960, to the Safety and Risk Management Division for forwarding to OSHA upon completion of the mishap investigation.

1.7.2 NASA Center safety and mission assurance officials will ensure all NASA mishaps and close calls are initially reported/recorded electronically on NF-1627, "NASA Full Safety Incident Report," and submitted in accordance with the IRIS instructions (see Appendix K) and the policies of the Director, Office of Health Affairs, at NASA Headquarters. Updates (including closure) will be submitted to IRIS within one week of receiving the data.

1.7.3 NASA Center safety and mission assurance officials will notify the Office of Inspector General (OIG) and the Office of the Chief Counsel immediately if it is reasonably suspected that a mishap resulted from criminal activity so that the OIG and Chief Counsel can appropriately coordinate their activities with the responsible workplace official.

1.7.4 NASA Center safety and mission assurance officials will notify the Safety and Risk Management Division during normal duty hours of mishaps and close calls that do not require immediate reporting but, in the judgment of the NASA Center safety and mission assurance official, may receive high visibility from the public, the press, or have recurrence control implications beyond the local Center.

1.7.5 NASA Center safety and mission assurance officials will initiate, facilitate, and coordinate all investigation activities and will be part of Center-level decisions on the acceptability of investigation activities or the need to reject investigation reports and establish a new investigation activity. They will also provide assistance to Appointing Officials in reviewing the adequacy of CAP's.

1.7.6 NASA Center safety and mission assurance officials will provide support to Appointing Officials (or their designees) to further develop and capture lessons learned topics identified in the final investigation report.

1.7.7 NASA Center safety and mission assurance officials will assist Appointing and Approving Officials in fulfilling their responsibilities.

1.7.8 NASA Center safety and mission assurance officials will involve themselves in acquisition strategy meetings as per NASA Federal Acquisition Regulations Supplement (NFS) Part 1807, "Acquisition Planning," to assure that the appropriate mishap and close call reporting, investigating, and evaluation criteria are incorporated into contracts.

1.8 Public Affairs Offices

Public affairs offices will assist in disseminating any preliminary information to the public relating to mishaps or close calls, and providing status, interim reports, and final reports to press and media representatives as provided in Appendix C and Appendix D.

1.9 Contracting Officers

Contracting officers must perform the following:

a. Incorporate applicable mishap and close call reporting and investigating procedures detailed in the NFS into contracts covering NASA programs and operations.

b. Involve safety and mission assurance and health personnel in the acquisition strategy planning activities for proposed contracts as detailed in NFS Part 1807, "Acquisition Planning."

1.10 Appointing Officials

1.10.1 Appointing Officials are responsible for the mishap investigation process and for appointing the mishap investigation members. The Appointing Official shall determine whether a mishap investigation board, mishap investigation team, Center-level investigation, or technical investigation team shall be used to investigate a mishap or close call, or alternately, to accept the investigation of another competent authority that may have jurisdiction.

1.10.2 The Appointing Official is responsible for the following:

a. Determining the level of NASA involvement, if any, when the mishap resulted from the actions of an outside source that was not involved in NASA operations.

b. Arranging for administrative and logistical support to the mishap investigation via the appointment letter.

c. Accepting the final mishap investigation report as fulfilling the requirements of the appointment letter and providing the report to the Approving Official for review.

d. Ensuring reporting organizations develop a CAP, accepting the CAP, and tracking and closing corrective actions resulting from any mishap investigation that the Appointing Official has appointed.

e. Providing a Portable Document File (PDF) electronic copy of the final, approved mishap investigation report to the appropriate level NASA Lessons Learned Information System (LLIS) program representative for posting to the NASA LLIS database. The copy that the Appointing Official provides to the LLIS database must first have been cleared for such release by the appropriate level NASA legal official, NASA import/export control official, and any other NASA program or policy official as appropriate. (Note: this should be undertaken during the report approval process.) This will ensure that the copy being released to the NASA LLIS is consistent with NASA policy and does not contain any restricted privacy information, classified information, or information that is subject to import/export control regulations.

f. Providing a final mishap summary report to the supporting safety and mission assurance organization and notifying the responsible organization that the corrective action plan is closed. (See Chapter 5.)

1.11 Approving Officials

The Approving Official has the final responsibility to review and approve the mishap investigation report as complete and in conformance with NASA policy. This includes coordination of the mishap report and any related lessons learned with an appropriate level NASA legal official, NASA import/export control official, NASA public affairs official, and any other NASA program or policy official as appropriate for compliance with NASA policies. The Appointing Official may also be the Approving Official for Center-level investigations.

1.12 Ex Officio Representative

1.12.1 The ex officio representative is the Associate Administrator for Safety and Mission Assurance, or his/her authorized representative, serving as a nonvoting participant in all investigation activities at his/her discretion. The ex officio representative is responsible for the following:

a. Assuring that the investigation was conducted in conformance with NASA policy and this NPG.

b. Assuring that the investigation process was fair, independent, and nonpunitive.

c. Providing advice and counsel to the investigation chair so that the investigation process could determine the root cause(s) of the mishap.

1.12.2 The ex officio representative will sign the final report demonstrating his or her belief that the above conditions have been satisfied.

1.12.3 For less than Type A investigations, the ex officio representative will be at a level consistent with the level of the appointment (e.g., will usually be a Center senior SMA official for Type B or a safety officer for Type C) and will be so documented in the appointment letter.

Ex officio representatives are not required for investigation activities directed or conducted by the safety or health organization.

1.13 Aircraft Management Office

The Aircraft Management Office (AMO) is responsible for coordinating the development of an Agency aviation safety program in accordance with Agency policies. As part of these responsibilities, the AMO will be notified of all aircraft mishaps and may participate in selected aircraft mishap investigations.

1.14 Operator of an Agency Aircraft

Upon occurrence of any NTSB aircraft accident (see Appendix A), the operator of an Agency aircraft shall immediately notify the Center safety office/program manager as well as the Safety and Risk Management Division by telephone, facsimile, or electronic mail during normal duty hours, or after duty hours call 1-866-230-NASA (1-866-230-6272). In addition, the operator of an Agency aircraft must report any event listed in paragraph 2.3.3.1 and provide the information specified in paragraph 2.3.3.2. The Safety and Risk Management Division has the responsibility to notify the NTSB.

1.15 NASA Officials Entering into Agreements

The NASA official entering into international agreements, interagency agreements, or memoranda of understanding between or among NASA and other federal agencies, international parties, and commercial partners shall include mutually acceptable elements of NPD 8621.1 , "NASA Mishap Reporting and Investigating Policy," and this NPG in the agreements to ensure that the process of reporting and investigating mishaps resulting from joint operations or other activities that affect NASA personnel or equipment are consistent with NASA policy.

1.16 Responsible Organization

The responsible organization is the organization that experienced the mishap. It will provide support as deemed necessary by the investigation chair for the mishap investigation process. After the corrective action plan is approved, the responsible organization will implement the corrective action plan as directed by the Appointing Official and provide status reports to the Appointing Official or designee.

1.17 Supervisors

1.17.1 When a supervisor is either witness to or informed of a mishap or close call, the supervisor must notify the appropriate emergency response personnel and the NASA Center safety and mission assurance official, health office, or program manager of the mishap (to the extent not already accomplished).

1.17.2 After the initial notifications are made, supervisors are responsible for providing further necessary assistance and control at the mishap site until emergency response, safety, or security authorities arrive. They are required to report the circumstances of mishaps and close calls in their immediate work area, support the investigation process and activities, and provide as much information as possible for, or submit, the NF-1627A, "NASA Initial Safety Incident Report."

1.17.3 Supervisors are required to develop mishap contingency plans (premishap plans) within their work area to support the procedures and guidelines in this NPG.

1.17.4 Supervisors may serve as the investigation official when tasked by an Appointing Official.

1.17.5 If the mishap results in a death, or personal injury requiring immediate hospitalization or in damage estimated to be in excess of $10,000 to Government or private property, the supervisor should also refer to NPG 3792.1 , "NASA Plan for a Drug-Free Workplace," to determine whether additional action outside the safety mishap reporting and investigating process should be taken.

1.18 Employees

All employees witness to or involved in a NASA mishap or close call are responsible for the following (to the extent physically able):

a. As soon as possible, notifying emergency response (911, fire, ambulance, security, etc.) of the need for any assistance.

b. As soon as possible, notifying a supervisor, management official, or a safety/health staff member of the circumstances of the mishap or close call.

c. Providing as much information as possible for witness statements and for the NF-1627A, "NASA Initial Safety Incident Report," and supporting the investigation process and activities.
á

DISTRIBUTION:
NODIS