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 |

3.1 Safeguarding the Site and Collecting Initial Evidence

3.1.1 Preserving the mishap site and any evidence is the first and one of the important actions necessary for a successful mishap investigation. The responsible organization, along with local safety personnel, security personnel, or emergency response personnel, shall take immediate action to prevent further injury to personnel and/or damage to any property, and safeguard (or impound) appropriate records and equipment that may be involved in the mishap, using preestablished procedures and mishap contingency plans (premishap plans). These procedures will normally be available from or controlled by the safety organization. It is suggested that these procedures be posted on the local network. Guidelines for preservation of evidence are in Appendix B, and guidelines for mishap site safety are in Appendix G

3.1.2 The responsible official should appoint an interim investigator, site commander, or team to control the site and conduct initial activities if there will be a delay in the initiation of a formal investigation. Normally this is covered in mishap contingency plans (premishap plans) or procedures for mishap or emergency response. The site should not be released for post investigation cleanup or other activities until released by the investigation authority or the responsible safety organization. Each Center should document the policy and procedures for release of impounded property and records.

3.1.3 The interim investigator, site commander, security personnel, emergency response personnel, or safety personnel may either request initial written statements from all persons (who are able) who were involved in or witness to the mishap, or document verbal accounts from such persons, as soon as possible after the site is secured and emergency actions taken. When members of the public may have witnessed a NASA mishap, appropriate measures will be taken to publicize the investigation for purposes of maximizing the amount of reliable testimony.

3.1.4 In the event that the medical member determines autopsies are required, time is of the essence, and the medical member, human factors member, or flight surgeon should coordinate and consult with the coroner or medical examiner to determine jurisdiction and arrange for the autopsies.

3.1.4.1 For international mishaps occurring on international programs and involving program participants, autopsies will be conducted in accordance with the bilateral/multilateral agreements.

3.1.4.2 For cases that result in fatalities involving flight mishaps, consideration should be given to obtaining support from the Armed Forces Institute of Pathology.

3.2 Determining the Level of Investigation/Selecting the Appointing Official and Approving Official

3.2.1 The type of mishap or close call will determine the level of investigation.

3.2.2 For Type A mishaps or selected high-visibility mishaps or close calls having a Type A mishap potential, the responsible Enterprise Associate Administrator or, in the case of a Type A mishap occurring at NASA Headquarters, the Associate Administrator for Headquarters Operations, will be the Appointing Official, unless the Administrator or Associate Administrator for Safety and Mission Assurance elect to be the Appointing Official. The Associate Administrator for Safety and Mission Assurance will approve the investigation board membership and be the Approving Official.

3.2.3 For Type B mishaps, delegated high-visibility mishaps, close calls having a Type B mishap potential, or mishaps or close calls delegated from Type A mishaps (see paragraph 3.2.2), the Center Director will be the Appointing Official and Approving Official with the advice of the Center safety official and notification to the Safety and Risk Management Division. (See Appendix F.)

3.2.4 For Type C and lesser mishaps and close calls, the Appointing Officials will be Center Directors, local safety and health (medical) officials, or other management level officials as designated in Center policies and procedures. Each Center's policies and procedures should address management responsibilities for establishing mishap investigations and the Center process for investigation and report approval and closeout for Type C and lesser mishap investigations. NASA lesser mishap investigations will follow the processes outlined in this NPG.

3.2.5 The final determination of the Approving Official may also be dependent upon the visibility and nature of the mishap and the decision of the Administrator or the Associate Administrator for Safety and Mission Assurance. The Associate Administrator for Safety and Mission Assurance will be the Approving Official for all Enterprise, Associate Administrator for Headquarters Operations, and Administrator-level boards. Center-level boards can be appointed and approved by the Center Director. When authority for appointment is delegated, the delegation letter will also direct the approval authority.

3.2.6 Additional Guidelines for Determining Levels of Investigation.

3.2.6.1 The Appointing Official should consider the following additional guidelines in determining the level of investigation:

a. The cost of the property damaged and associated impacts. (See Appendix A.)

b. Schedule delay impacts.

c. Mission or test failures that significantly reduce the potential for successful achievement of mission and/or test objectives, or affect other government organizations or the general public.

3.2.6.2 The Associate Administrator for Safety and Mission Assurance must concur with the approach and level of assignment for investigation for a Type A mishap or high-visibility mishap or close call.

3.3 Appointing Official Procedures

3.3.1 For Type A mishaps, or selected high-visibility mission failures or close calls, the expected Appointing Official (Enterprise Associate Administrator, Associate Administrator for Headquarters Operations) will contact the Associate Administrator for Safety and Mission Assurance as soon as possible (generally within 1 hour of initial notification) to determine if either the Administrator or the Associate Administrator for Safety and Mission Assurance desires to be the Appointing Official. If both elect not, the Appointing Official will establish a "quick reaction teleconference" to plan and discuss the mishap investigation process and the initial actions to be taken. Because of the many and diverse situations that could constitute a mishap, preselection of personnel to constitute a mishap investigation board is normally not possible except by description or job title. For major mishaps, the appropriate Associate Administrator, the Associate Administrator for Safety and Mission Assurance, Center Director, program manager, and others as necessary will assemble the recommendations for board constituency. If the mishap occurs during nonduty hours, the teleconference will be conducted at a time selected by the Enterprise Associate Administrator.

3.3.2 For Type A mishap investigation boards (including high-visibility close calls), the Appointing Official must obtain the concurrence of the Associate Administrator for Safety and Mission Assurance for the level of the investigation and membership proposed for the investigation board.

3.3.3 The responsible Enterprise-level Appointing Official, with the concurrence of the Associate Administrator for Safety and Mission Assurance, may delegate appointing and approving authority to a Center Director or program/project manager, or elevate the level of investigation of a less serious mishap or close call if, in the judgment of the Enterprise-level Appointing Official, it is warranted due to the potential for a major mishap or its visibility. Procedures for the delegated level will apply.

3.3.4 If delegated the authority, program/project managers will appoint a chairperson and members of investigation for mishaps within their program/project. These boards are formed when only the functions, resources, and activities of particular programs are affected, or where there is a prearranged agreement with the appropriate Enterprise Associate Administrator and the Associate Administrator for Safety and Mission Assurance.

3.3.5 For Type B mishaps, other mission failures, and close calls not considered above, Center Directors, program managers, or the Associate Administrator for Headquarters Operations will serve as the Appointing Official and will appoint the chairperson and members of the investigation board. Advice of the responsible safety official and notification to the Safety and Risk Management Division are required. (See Appendix F.)

3.3.6 Type C and lesser mishaps and close calls that do not require a Type A or B mishap investigation board will be investigated in accordance with Center-level procedures which, as a minimum, will address management responsibilities for establishing mishap investigations, the investigation report approval and closeout process, the development and acceptance of corrective action plans, and development and approval of lessons learned.

3.3.7 Lesser mishaps can be delegated upward upon the request of either level of Appointing Official. The procedures applicable to the level to which the responsibility is delegated will be followed.

3.3.8 NASA Contractor Mishaps.

3.3.8.1 Contractors will establish mishap investigations and provide reports as specified in their contract and as specified in the NFS 1852.223-70. In those cases that are not NASA mishaps, i.e., solely involve a contractor accident or incident arising out of work performed under a NASA contract (which the contractor is required to investigate pursuant to NFS 1852.223-70), the NASA Appointing Official is not required to appoint a separate NASA mishap investigation board.

3.3.8.2 NASA mishaps arising out of contractor operations.

For those NASA mishaps resulting from NASA contractor operations or contractor personnel, the Appointing Official may delay the formation of a separate NASA mishap investigation board (or activity), pending the review of the contractor report required by NFS 1852.223-70, provided the deficiencies involved are confined to technical or operational matters and have no policy change implications. The contractor report in such a case will be subjected to a NASA review and approval process that conforms to this NPG. If the responsible NASA Appointing Official, as a result of the review and approval process, or otherwise, believes that the contractor report is not adequate for purposes of recurrence prevention or is not suitably independent, the Appointing Official shall appoint a NASA investigation pursuant to this NPG.

3.3.9 For all types of mishaps or close calls, after the level of investigation has been determined by the responsible group or official, the Appointing Official (if it is determined that an Appointing Official is needed) will prepare an "appointment letter." The appointment letter identifies the investigation's chairperson, membership (including ex officio), responsibilities, the desired course of action along with timelines, and the Approving Official. (See Appendix H.) The board membership is determined with the advice of the Office of the General Counsel or the Office of the Chief Counsel, as appropriate.

3.3.10 When serving as Appointing Official, the Associate Administrator for Safety and Mission Assurance must consult with the appropriate Enterprise Associate Administrator in the selection of personnel appointed to chair or serve as board members. The Associate Administrator for Safety and Mission Assurance or Enterprise Associate Administrator will also contact the NASA Administrator for a major mishap (generally within 1 hour of the initial notification of the mishap) to determine if the Administrator wishes to exercise appointment authority.

3.4 Exceptions to the Normal Appointment and Investigation Process

3.4.1 Flight anomalies, mishaps, and close calls occurring in the Space Shuttle and International Space Station programs may be investigated by technical level reviews instead of a mishap investigation board due to the existence of a formally documented and robust technical investigation and corrective action process in place and the fact that results are reviewed and approved through the program and flight readiness process, which includes Office of Safety and Mission Assurance participation. The Associate Administrator for Safety and Mission Assurance must be consulted before proceeding to appoint a technical level review in lieu of a Type A or B mishap board.

3.4.2 Mission failures occurring in the Balloon and Sounding Rocket programs managed by the Goddard Space Flight Center (GSFC)/Wallops Flight Facility (WFF) will be investigated by the normal project-level technical investigation process. However, if the mission failure results in death, injury/illness, or unanticipated damage to government or nongovernment property, reporting and investigating procedures detailed in this NPG will be followed. Program officials will prepare an annual fiscal year report and submit to program and SMA officials from GSFC and the NASA Safety and Risk Management Division for their review. These organizations will review the actions taken by the respective programs to assure that corrective actions and lessons learned are derived and used to preclude future mission failures. All mission failures and close calls will be reported by program officials to the appropriate safety officials at the GSFC/WFF. In addition, these occurrences will be recorded on NF-1627 and entered into the IRIS and LLIS.

3.4.3 Mission failures occurring in space or aeronautical programs without human crews, that use better, faster, cheaper techniques, which do not result in death, injury/illness, or unanticipated damage to nongovernment property, may be investigated by technical investigation teams upon the approval of the Associate Administrator for Safety and Mission Assurance. Technical investigation teams may consist of representation from contractors and foreign space organizations outside of NASA when a joint venture mission failure occurs. Complete investigation reports will be prepared and distributed to the program manager and the Center safety office. These reports will document root cause(s) of the mission failure, lessons learned, and recommended corrective actions. All mishaps and close calls will be reported by program officials to the appropriate safety officials, and will be recorded on NF-1627 and entered into the IRIS.

3.4.4 Mission failures or NASA mishaps for long-duration missions where the program/project structure has been disbanded will still be investigated per this NPG. If there is no recoverable physical evidence available, the investigation will use existing program/mission documentation and any collected mission data along with applicable analytical techniques to determine the probable root cause(s) of the mishap. A CAP will not be required of the project/program. The responsible organization must develop lessons learned for possible application to existing or future programs.

3.4.5 Mission failure of remotely piloted vehicles, where the risk of loss or damage has been formally accepted by the program, may be investigated by technical investigation teams upon the approval of the Associate Administrator for Safety and Mission Assurance. The program should investigate the loss as a technical failure to understand the root cause(s) and eliminate recurrence. If, however, the loss of the remotely piloted vehicle caused damage to, or loss of, personnel, property, or equipment in addition to the remotely piloted vehicle, it must be reported and investigated as a mishap.

3.4.6 The NASA Administrator may activate the "Office of Space Flight (OSF) Space Flight Operations (SFO) Contingency Action Plan," in the case of a high-visibility, mission-related Space Shuttle, International Space Station, or contingencies related to the processing and/or flight of payloads manifested on contract Expendable Launch Vehicles. This plan is established by the Office of Space Flight to assign immediate responsibilities and outline actions that must be taken in the event that a space flight contingency occurs. A standing mishap investigation board, consisting of seven members and supported by the Office of Space Flight at NASA Headquarters, is identified in the plan and activation is anticipated for events involving serious injury, loss of life, or significant political, media, or public interest.

3.4.7 Accepted investigations by other parties. NASA mishaps or close calls involving a NASA employee in the line of duty may not require a separate NASA investigation if the NASA Appointing Official accepts an investigation by other authorities if it appears to be independent and adequately address recurrence control. Examples include the following:

a. Traffic accidents involving NASA employees in the course of their duty when investigated by local authorities (sheriff, state police, coroners, etc.) having jurisdiction.

b. An injury or fatality when there is substantial reason to believe the incident is the result of criminal or terrorist acts to NASA employees and when investigated by local or Federal law enforcement authorities such as the Federal Bureau of Investigation, the Bureau of Alcohol, Tobacco, and Firearms, the Department of State, the Drug Enforcement Agency, or the Office of Inspector General.

c. Fatalities or injuries as a result of commercial transportation mishaps involving NASA personnel on official business and when investigated by authorities having jurisdiction such as the Federal Aviation Administration and the NTSB.

d. Injuries or fatalities investigated by OSHA. Note: A NASA investigation for the systemic root cause(s) of the mishap should be accomplished on a noninterference basis in parallel to any OSHA-led investigation of a NASA mishap.

3.5 Membership of an Investigation Board, Team, or Activity

3.5.1 An investigation board is composed of chairperson, executive secretary, board members, ex officio representative, consultants, observers, advisors, and support staff as determined by the Appointing Official. The chairperson, executive secretary, and board members must be Federal personnel. The severity and complexity of the mishap to be investigated will dictate the total number of members as well as the number of tasks assigned to a member.

3.5.2 The term "Chairperson" designates the individual in charge of any type mishap investigation from a full board to a two-person investigation team.

3.5.3 The Associate Administrator for Safety and Mission Assurance or his or her designee may participate as deemed necessary as an ex officio, nonvoting member, of all mishap investigation board activities. For lower level activities, the ex officio representative can be from the local SMA or safety organization. (See Chapter 1 for specific responsibilities.)

3.5.4 The chairperson, members, the ex officio representative, and support staff will be appointed by formal memorandum and will be relieved of other duties while they are engaged in board activities. (See Appendix H for a sample appointment letter for board investigations.)

3.5.5 The majority of board or team members should be from NASA Centers, organizations, or programs independent of the Center, operation, or the program in which the mishap occurred. In addition, members shall have no vested interest in the outcome of the investigation. When needed, other members can be appointed from Federal Agencies having technical expertise in the area of investigation for cases where the necessary expertise cannot be obtained within NASA. For international programs, members will be as provided in bilateral/multilateral or international agreements.

3.5.6 Boards or teams will consist of an odd number of voting members - at least five Federal employees for Type A boards and at least three Federal employees for Type B boards.

3.5.7 Non-Federal employees may serve as observers, advisors, or consultants and may be excluded from any deliberations at the discretion of the board chairperson and will not be allowed to read, or listen to, witness testimony.

3.5.8 When possible, members will be selected from personnel who have completed the NASA mishap investigation course (or equivalent) and have received refresher training every 3 years.

3.5.9 Members shall have sufficient experience and technical expertise to understand the technology and management interfaces related to the mishap.

3.5.10 Legal personnel will be appointed as advisors (nonvoting) to the board to provide legal and policy assistance and guidance to the investigative process.

3.5.11 A qualified public affairs officer will be designated as an advisor (nonvoting) to the board. This person will advise and assist the board in developing and coordinating information to be released to the public in accordance with NASA policies. (See Appendix C and Appendix D.)

3.5.12 For other specific board members and their investigative roles, see Appendix F.

3.5.13 Lower level teams or investigation activities can be composed of one or more NASA employees meeting criteria as above. For some lost time mishaps, incidents, or close calls, safety or health chartered investigations may be appropriate. Ex officio representatives are not required for investigation activities directed or conducted by the safety or health organization.

3.6 Support for the Investigation

The Enterprise or Center experiencing the mishap will provide support for mishap investigation board activities. The host Center is responsible for administrative and logistical support for the board. Responsibility for administrative and logistical support will be noted in the appointment letter.

3.7 Conducting the Investigation

3.7.1 Once the mishap investigation membership is selected, the first action taken is to quickly familiarize the investigator(s) with their roles and responsibilities and to provide them with the appropriate tools to conduct a proper investigation. The safety and mission assurance office associated with the responsible organization will provide the needed information to the investigator(s). Additionally, the local safety and mission assurance office may provide an ex officio representative, unless Headquarters is participating, to assess the progress of the investigation and assure the adequacy of the investigation process to the Center Director. Once appointed, the mishap investigation board, team, or mishap investigator is responsible for the mishap site and control of all evidence associated with the mishap. Only the board chairperson or mishap investigator may release the site or evidence for activities other than those supporting the investigation.

3.7.2 The mishap investigation board or investigator is responsible for investigation of the mishap. Safety personnel, emergency response personnel, security personnel, and other personnel will turn over all initial evidence gathered at the scene of the mishap. The responsible organization will support the mishap investigation board or mishap investigator with records, data, experts, etc., as requested. The Appointing Official will arrange for any necessary administrative support, including, but not limited to, meeting rooms, clerical help, photographic support, and laboratory analysis, as requested. Also, the Appointing Official will monitor the progress of the mishap investigation board or mishap investigator and provide any management concerns to the mishap investigation board or mishap investigator. The SMA office associated with the responsible organization will support the mishap investigation board or mishap investigator and the Appointing Official by providing a facilitator, experts, etc., as requested.

3.7.3 The mishap investigation board or mishap investigator will use a structured technique to collect all available data, construct a timeline of events, conduct witness interviews, and to analyze the mishap occurrence to determine what happened, when it happened, and why it happened. Typical steps in a mishap investigation are found in Figure 3-1. Appendix E-1 provides a suggested witness clause that should be read and explained to all witnesses at the start of their formal interview. Appendix E-2 provides guidelines for obtaining eyewitness accounts and witness testimony. Guidelines for evidence and data analysis can be found in Appendix I. The mishap investigation board or mishap investigator should strive to find both the technical cause(s) of the mishap and the human cause(s) of the mishap. The Management Oversight and Risk Tree (MORT) investigation tool provides a structured method of analyzing mishap data. This tool can be very helpful in identifying technical and management root cause(s) of the mishap, and it is highly recommended that at least one board member be familiar with this technique (see Appendix I). Mishap investigation checklists are provided in Appendix J.

3.7.4 Typical Steps in a Mishap Investigation.

Figure 3-1 shows the typical steps involved in a mishap investigation. Appendix F provides specific details for reporting requirements, organizational responsibilities, and Appointing/Approving Officials.

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3.7.5 The mishap investigation report will contain a description of the structured analysis technique used by the mishap investigation board or investigator for assuring all causative possibilities are explored. The mishap investigation board or investigator will document the what, when, where, and why of the mishap in the mishap investigation report. The focus and priority of the investigation report is the determination and discussion of the root cause(s) of the mishap. The report will also include significant observations, findings, and recommendations. The report will include proposed corrective actions if requested in the appointment letter, and proposed lessons learned topics for future development. The report should be technically accurate, properly documented, well defined, easily understood, and consistent with the format in Appendix H or as specified by the Appointing Official. Witness statements will be kept separate from the main portion of the report so that they can be easily separated and withheld from release with the main report.

3.7.6 The final report will be signed by all board members. Minority reports can be provided if needed in the event that agreement is not reached among board members. Observers, advisors, and consultants may sign the report at the discretion of the chairperson. The ex officio representative will also sign the report attesting to their belief to the following:

a. The investigation was conducted in conformance with NASA policy and this NPG.

b. The investigation process was fair, independent, and nonpunitive.

c. Adequate advice was provided to the chairperson so that the root cause(s) of the mishap could be determined and documented.

3.7.7 The mishap investigation board or mishap investigator will provide the mishap investigation report to the Appointing Official in accordance with Chapter 4.
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