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NASA Procedures and Guidelines |
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| | TOC | ChangeHistory | Preface | Chapter1 | Chapter2 | Chapter3 | Chapter4 | Chapter5 | Chapter6 | Chapter7 | AppendixA | AppendixB | AppendixC | ALL | | |||||
Note: A notional timeline of the mishap investigation process, from the time of a mishap to the time that the corrective action plan and lessons learned are generated, is in Appendix C.
3.1.1 After the initial notifications are made, the supervisor shall provide any necessary assistance to safe the mishap site until the emergency response and/or personnel from the Center safety office arrive (Requirement 44432).
3.1.2 Upon notification of a mishap, the Center safety office shall initiate the Center Mishap Preparedness and Contingency Plan (Requirement 44433).
3.1.3 In the event of a program/project mishap, the program shall activate its Mishap Preparedness and Contingency Plan (Requirement 44434).
3.1.4 In accordance with the Center Mishap Preparedness and Contingency Plan, the incident commander, with support from the responsible organization, IRT, Center safety office, Center security office, emergency response personnel, and supervisor, shall take immediate action to prevent further injury to personnel and/or damage to any property and secure the site (Requirement 44435).
3.1.5 The incident commander and emergency response personnel shall have the authority to take action to mitigate dangerous conditions, direct emergency response actions, and/or clean up a hazardous materials release (Requirement 44436).
3.1.6 The Center safety office and incident commander shall ensure protection of personnel from residual hazardous material prior to entry into the mishap site (Requirement 44437).
3.1.7 The Center safety office and/or incident commander shall stipulate the type of personal protective equipment (PPE) required (Requirement 44438).
3.1.8 Every professional supporting the investigation, including the IRT and investigating authority, shall adhere to the PPE requirements as defined by the Center safety office personnel or incident commander (Requirement 44439).
After emergency response has been initiated, within 1 hour of the occurrence of a Type A mishap, Type B mishap, high-visibility mishap, or high-visibility close call, the Center safety office shall notify Headquarters as described in paragraph 1.5.3 and NPR 7100.1, paragraph 11.4.1 (Per NPR 7100.1, paragraph 11.4.1, this includes immediately reporting a human test subject injury or fatality that resulted in a loss of life, a permanent disability, hospitalization, extensive first aid, or lost workday(s)) (Requirement 44440).
In accordance with the Center or program/project Mishap Preparedness and Contingency Plan, the Center safety office or other designee shall deploy the IRT to initiate and support the investigation until a determination can be made as to the need for, and selection of, an investigating authority (Requirement 44441).
The AA/OPA (or designee), with the assistance of the Center safety office, IRT, and CD or ED/OHO shall immediately release information to the press and media to alert Center personnel and the public of any known hazards and their potential effects and provide instructions that will mitigate the risk and harm (Requirement 44442).
3.5.1 The incident commander, with support from the responsible organization, IRT, Center safety office, Center security office, emergency response personnel, and supervisor, shall take immediate action to prevent further injury to personnel and/or damage to any property, secure the site, limit unnecessary access, and preserve evidence (Requirement 44444).
3.5.2 Evidence preservation actions shall not hamper essential rescue operations (Requirement 44445).
3.5.3 In the event that a fatality occurred, a Federal employee that is part of the IRT (preferably a medical professional) or the physician that serves as a member of the investigating authority shall coordinate and consult with the Office of General Counsel and the coroner or medical examiner to determine medical jurisdiction and arrange for forensic analysis (i.e., autopsy) (Requirement 44446).
3.6.1 The Center safety office, with the support of the IRT, Center security office personnel, and supervisor, shall impound all appropriate data, records, equipment, and facilities that may be involved in the mishap to prevent their unauthorized use or modification (Requirement 44448).
3.6.2 The Center safety office shall control access to all impounded items until they are released by the investigating authority per the procedures in the Center Mishap Preparedness and Contingency Plan (Requirement 44449).
3.6.3 Data and records, regardless of format, to be impounded may include, but are not limited to, check-out logs, test and check-out record charts, launch records, weather information, telemetry tapes, video tapes, audio tapes, time cards, training records, work authorization documents, inspection records, problem reports, notes, e-mail messages, and automated log keeping systems and procedures.
3.6.4 For NASA mishaps occurring on international programs and/or involving program participants, autopsies shall be conducted in accordance with the bilateral/multilateral agreements (Requirement 44451).
3.6.5 For NASA mishaps occurring on international programs and/or involving international program participants, data, records, equipment, and facilities shall be impounded in accordance with the bilateral/multilateral agreements (Requirement 44452).
If the mishap results in a fatality or personal injury requiring immediate hospitalization, or in damage estimated to be in excess of $10,000 to government or private property, the supervisor shall initiate post-accident/unsafe practice testing per NPR 3792.1, NASA Plan for a Drug-Free Workplace (Requirement 44453).
a. All written witness statements obtained within the first 24 hours of the occurrence of a mishap or close call shall be considered privileged and protected (Requirement 44455). Where possible, written witness statements should be collected on a NASA form that includes the statement of privilege as shown in Figure 6.
b. All verbal witness statements and written statements given after 24 hours as part of a NASA mishap investigation, where the witness was explicitly informed that his/her account will not be released, shall be considered privileged and protected (Requirement 44457).
c. When privilege has been granted by the IRT, Center safety office, or investigating authority, NASA shall make every effort to keep witness testimony (both written and verbal) confidential and privileged to the greatest extent permitted by law (Requirement 44458) This privileged information will be strictly limited to only the information provided directly by the witness for the safety investigation.
d. The witness shall not be given a copy of the privileged written statement or transcripts of verbal witness statements given in the course of a NASA mishap investigation (Requirement 44460). (If witness statements or transcripts of witness testimony are provided to a witness, NASA cannot ensure that it remains privileged and confidential.)
e. The Center safety office, with the support of the IRT, shall either request initial written statements from all persons who were involved in or witness to the mishap or document verbal accounts from such persons (Requirement 44462).
f. Before a verbal witness statement is taken or an interview begins, the IRT, Center safety office, or investigating authority shall tell the witness whether the information gathered during the interview is confidential and privileged or not confidential and not privileged (Requirement 44463).
Note: If the same individual is interviewed multiple times, this should occur each time the individual is interviewed.
g. When conducting privileged witness interviews, the NASA investigating authority shall only have Federal employees present at the interview (with the exception of the interviewee), unless a contractor has been hired specifically to support interviews or provide technical guidance to the Board during the interviews and has signed a nondisclosure agreement prepared by General Counsel prior to participating in the interviews (Requirement 44465).
h. When it is expected that an external investigating body will be the sole mishap investigation authority (e.g., for catastrophic vehicle failure such as Space Shuttle or International Space Station loss, or airplane loss), NASA shall not grant privilege to witnesses for either written witness statements or verbal witness statements, even when those statements are taken within the first 24 hours after the mishap (Requirement 44466).
Note: If an outside investigating authority, such as a congressionally appointed mishap investigating board or the National Transportation Safety Board (NTSB), conducts a mishap investigation for a mishap involving an airplane or catastrophic vehicle loss, they are not required to comply with NPR 8621.1. Consequently, NASA is unable to ensure that privilege will be maintained and may not be able to withhold privileged statements from the investigation authority.
i. When the IRT, Center safety office, or investigating authority decides to take a verbal statement or interview a witness and keep that witness interview confidential, the interviewer shall read the statement in Figure 6 of this NPR and inform the witness that:
(1) The oral statement (taken during interview) and/or written statement will be retained as part of the investigation report background files but will not be released as part of the mishap report (Requirement 44469).
(2) NASA will make every effort to keep the testimony privileged to the greatest extent permitted by law (Requirement 44470).
Figure 6. Statement That Shall Be Read to Witness at the Start of the Formal Interview
The purpose of this safety investigation is to determine the proximate cause(s) and root cause(s) of the mishap that occurred on _____________ and to develop recommendations toward the prevention of similar mishaps. It is not our purpose to place blame or to determine legal liability. Your testimony is entirely voluntary, but we hope that you will assist the investigating authority to the maximum extent of your knowledge in this matter. Your testimony will be documented and retained as part of the mishap report background files but will not be released with your name as part of the mishap report. The investigating authority will make every effort to keep your testimony confidential and privileged to the greatest extent permitted by law. For the record, please state your full name, title, address, employer, and place of employment. |
3.9.1 Release of Information Concerning Casualties and Extensive Property Damage
3.9.1.1 The NASA Headquarters OPA must approve the release of all information related to NASA Type A mishaps and Type B mishaps, prior to its release to the press or public (Requirement 44473).
3.9.1.2 The CD or ED/OHO shall coordinate release of all information to the press and the public via the Center PAO (Requirement 44474).
3.9.1.3 The Center PAO shall, as appropriate, disseminate any preliminary information, video, and imagery to the public relating to the mishap (Requirement 44475).
3.9.2 Release of Information Concerning NASA-Owned Property Damage on Other Than Government-Owned Facilities, Overseas Tracking Stations, and Contractor-Owned Plants
3.9.2.1 When a mishap involving extensive damage to, or destruction of, NASA property occurs at other than government-owned facilities, overseas tracking stations, or contractor-owned plants, the contractor, tracking station manager, base commander, or other authority shall inform their point of contact at NASA (Requirement 44477).
3.9.2.2 The Center safety office cognizant of the mishap shall confirm that the mishap occurred to the NASA-owned property on other than government-owned facilities (Requirement 44478).
3.9.3 Release of Information to the Press and Public Concerning Casualties
3.9.3.1 NASA Employee Casualties. When a NASA employee is killed or receives a permanent disability within the confines of a Center, the Center PAO shall promptly announce to the public that a mishap has taken place and injuries or fatalities have occurred (Requirement 44480).
a. In the case of a fatality, the CD or ED/OHO or appropriate Headquarters Official-in-Charge, shall ensure that notification of the family has been made prior to release of the victim's name (Requirement 44481).
b. All initial announcements shall include what is known at the time, including the injuries or fatalities that have occurred and when additional information is expected to be available (Requirement 44482).
c. In the case of fatalities, release of the victim's name(s) shall be made as soon as possible after the notification of the next of kin (Requirement 44483).
3.9.3.2 Military and Other Agency Personnel Casualties. The procedures for public announcements of mishaps involving military and other Federal personnel (including astronauts) detailed to NASA shall be the same as for NASA employees, with these additional requirements:
a. The CD or ED/OHO shall inform the appropriate military service headquarters or other Federal agency of the mishap (Requirement 44485).
b. The CD or ED/OHO shall inform the Center PAO that the military service organization or other Federal agency has been notified of the mishap (Requirement 44486).
c. When the Center is on a military base, release of a victim's name shall be made according to procedures previously agreed upon by the base commander and CD or ED/OHO (Requirement 44487).
3.9.3.3 Contractor and Grantee Employee Casualties. NASA does not assume responsibility for the release of information concerning mishaps involving contractor or grantee employees, except as follows:
a. When a Type A mishap or Type B mishap occurs on a Center or at Headquarters or involves a NASA-managed program managed by that Center, the CD or ED/OHO, in coordination with the Center PAO/Headquarters PAO, shall announce as soon as possible that a mishap has occurred, as well as the number of known fatalities and/or injured (Requirement 44489).
b. The CD or ED/OHO shall not announce the identity of contractor or grantee personnel involved (Requirement 44490).
c. When a mishap occurs at a contractor's/grantee's plant engaged in NASA work, NASA has no responsibility to release information concerning the mishap and shall not issue statements as to the cause and extent of injury or damage (Requirement 44491).
3.9.3.4 Center Visitor Casualties. When a Type A mishap or Type B mishap occurs which involves visitors on a Center or at Headquarters, the CD or ED/OHO, in coordination with the Center PAO or Headquarters PAO, shall announce as soon as possible that a mishap occurred and the number of known fatalities and/or injured (Requirement 44492).
3.9.3.5 Overseas Mishaps. When a Type A mishap or Type B mishap occurs overseas, for example, at a tracking station or during an overseas rocket or balloon campaign involving NASA personnel, the Official-in-Charge shall release mishap information through the U.S. consular office in accordance with policies and procedures established by that office (Requirement 44493).
a. If the program involves foreign participation, the release of information shall be coordinated with the foreign entities sponsoring and participating in the program (Requirement 44494).
b. The Official-in-Charge shall notify, by the most expeditious means, the Chief/OSMA and the appropriate MDAA that a mishap has occurred overseas (Requirement 44495).
c. The MDAA shall notify, by the most expeditious means, the AA that a mishap has occurred overseas (Requirement 44496).
d. The AA shall immediately notify the Administrator, the Deputy Administrator, the AA/OPA; the Assistant Administrator, Office of External Relations; the Office of the General Counsel, as well as other appropriate staff that a mishap has occurred overseas (Requirement 44497).
3.10.1 Within 8 hours of a work-related mishap involving death of a Federal employee, or the hospitalization for inpatient care of three or more employees (provided at least one is a Federal employee), the Center safety office shall notify OSHA per paragraph 1.5.4 of this NPR (Requirement 44499).
3.10.2 OSHA notification is required for any fatality and for three or more hospitalizations for inpatient care that occur up to 30 workdays after the respective mishap (Requirement 44500).
3.11.1 For Type A mishaps, Type B mishaps, high-visibility mishaps, and high-visibility close calls, the Center safety office shall send an electronic notification to OSMA/SARD containing information found in paragraph 1.5.3.2 of this NPR (Requirement 44502).
3.11.2 Within 24 hours, the Center safety office shall ensure that all NASA mishaps and close calls are recorded in IRIS in accordance with paragraph 1.8.1 of this NPR (Requirement 44503).
Note: Close calls involving aircraft may be entered into the NAARS in lieu of IRIS.
| TOC | ChangeHistory | Preface | Chapter1 | Chapter2 | Chapter3 | Chapter4 | Chapter5 | Chapter6 | Chapter7 | AppendixA | AppendixB | AppendixC | ALL | |
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