NASA Procedures and Guidelines
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NPR 8621.1B Eff. Date: May 23, 2006 Cancellation Date: June 21, 2019	NASA Procedural Requirements for Mishap and Close Call Reporting, Investigating, and Recordkeeping w/Change 7 (07/15/2013)
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Chapter 5. Mishap Investigation Process

5.1 Overview of the Mishap Investigation Process

5.1.1 The investigating authority shall use a structured technique to collect and review all available data, construct a timeline of events, conduct witness interviews, reconstruct the mishap or close call, and analyze the mishap occurrence to determine what happened, when it happened, and why it happened (Requirement 44575).

5.1.2 Figure 7 illustrates the typical steps that the investigating authority shall perform during the mishap investigation (Requirement 44576).

Figure 7. Typical Steps in the Mishap Investigation

5.2 Prepare for the Investigation

The investigating authority shall perform the following activities prior to arrival at the mishap site or shortly thereafter:

a. Mishap investigation overview training (Requirement 44578).

(1) The Investigating Authority members and advisors shall take the NASA "Introduction to Mishap Investigation Training" upon their assignment to the investigation to familiarize themselves with NASA mishap investigation policies and procedures and root cause analysis (Requirement 44579). (Investigating authority members and advisors may opt out of the training if they have taken it within the last 12 months.)

b. Assessment of personnel resources (Requirement 44581). The chairperson may make a request to the appointing official to modify the investigating authority's membership to fill technical and/or analytical expertise gaps, provide management experience and knowledge, or eliminate members that have a conflict of interest.

(1) For Type A mishaps, Type B mishaps, high-visibility mishaps, and high-visibility close call investigation boards, the Chief/OSMA and Chief Engineer shall concur on membership changes prior to any MIB member additions or deletions (Requirement 44583).

c. Identification and selection of consultants as necessary (Requirement 44584).

d. Establishment of member duties, meeting times, and investigation schedules (Requirement 44585).

5.3 Verify that the Site is Safe and Secured and Ensure Evidence is Preserved/Impounded

5.3.1 Verify that the Mishap Site is Safe and Secured.

5.3.1.1 Upon arrival, the chairperson shall verify the site is safe and secured (Requirement 44588).

5.3.1.2 Neither the investigating authority nor the IRT has the authority to direct emergency response actions or activities to clean up a hazardous materials release (Requirement 44589).

(1) These actions shall be directed by the incident commander (Requirement 44590).

5.3.2 Ensure that Evidence is Preserved and Impounded.

5.3.2.1 The chairperson shall ensure that all the appropriate perishable evidence has been collected, photographed, documented, and/or impounded (Requirement 44592).

5.3.2.2 The chairperson shall ensure that all the necessary data, records, and equipment have been impounded and are being stored in a secure site (Requirement 44593).

5.3.2.3 The IRT, Center safety office personnel, emergency response personnel, and Center security office personnel shall provide the investigating authority with all evidence gathered at the scene; all data pertaining to the investigation, including impounded records; a status of impounded records/equipment; and a description of the actions taken (Requirement 44594).

5.3.2.4 When there is a mishap involving an injury or a fatality, the chairperson shall appoint a Federal employee to serve as an evidence custodian(s) who will implement the "chain of custody process" documented in the Program Mishap Preparedness and Contingency Plan to provide physical security over and controlled access to the injured/deceased personal effects and related sensitive material (Requirement 44595).

5.4 Gather Physical Evidence and Facts

5.4.1 The investigating authority should evaluate three general sources of data (material, personnel, and records) during the investigation. The material area includes all parts, components, and support facilities directly or indirectly involved. The personnel area includes all persons associated with the activities immediately surrounding the mishap, such as the flight crew, launch complex personnel, maintenance personnel, test personnel, operations personnel, range safety personnel, management and supervisory personnel, and witnesses and their associated training records, certification, e-mail, notes, and other records. The records data, regardless of format, include all records, telemetry, recordings, analyses, inspections, and historical data associated with the specific equipment, operations, and operating personnel.

5.4.2 The investigation should not be limited to data and records generated concurrently with, or as a result of, the mishap. It should also include historical, environmental, operational, psychological, and other factors bearing on the situation.

5.5 Interview Witnesses

5.5.1 It is NASA's philosophy to interview witnesses rather than interrogate them. "Interview" connotes a cooperative meeting where the interviewer approaches the interviewee as an equal. The cooperation of the interviewee is sought; encouragement is given to tell the story freely without interruption or intimidation. An interview is usually conducted informally with a voluntary or cooperative answering of questions. However, the investigating authority may also conduct more formal interviews. Even in those cases, witnesses shall not be sworn in (Requirement 44601).

5.5.2 The investigating authority shall interview mishap witnesses with two basic objectives in mind:

a. To find out what the witness observed or did (Requirement 44603).

b. To find out the witness's opinion of potential cause(s) of the mishap (Requirement 44604).

5.5.3 The investigating authority conducting the witness interviews shall perform all steps as listed in paragraph 3.8 of this NPR (Requirement 44605).

5.6 Review and Analyze Data

5.6.1 The investigating authority shall determine the sequence of events and document them in a timeline (Requirement 44607).

5.6.2 The investigating authority shall create a fault tree, or perform an equivalent analysis, to identify all potential cause(s) and contributing factor(s) to the mishap and the relationships among them (Requirement 44608).

Note: A fault tree should be used by the MIB to demonstrate that all potential causes of the mishap have been evaluated. An event and causal factor tree should be used to represent all the events that did occur, and the relationship between the proximate, intermediate, and root causes.

5.6.3 The investigating authority shall analyze all potential cause(s), including both technical and human cause(s) (Requirement 44610).

5.7 Draw Conclusions and Document Findings

5.7.1 The investigating authority shall evaluate all information collected during the course of the investigation, including, but not limited to, physical evidence, witness statements and testimony, and analytical results from testing and analysis; draw conclusions concerning what happened and why it happened; and document these as investigation findings (Requirement 44612).

5.7.2 All findings shall be supported by facts (Requirement 44613).

5.8 Generate Recommendations

5.8.1 At a minimum, the investigating authority shall develop recommendations that address both the proximate cause(s) and the root cause(s) to prevent recurrence of the mishap or close call or similar mishaps and close calls (Requirement 44615).

5.8.2 The investigating authority shall verify that the recommendations are clear, verifiable, achievable, and traceable to at least one significant finding (Requirement 44616).

Note: Each finding does not require a recommendation except as required in paragraph 5.8.1.

5.8.3 The investigating authority shall prioritize the recommendations (Requirement 44617).

5.8.4 At any time during the investigation, the investigating authority may recommend to the appointing official that immediate corrective actions be taken to ensure the safety of ongoing operations internal or external to NASA.

5.8.5 The appointing official shall communicate recommendations outside his/her authority to the responsible NASA organization or external body for implementation of corrective measures Requirement 44619).

5.9 When and How to Turn Over for Criminal Investigation

If it is reasonably suspected that a mishap resulted from criminal activity, the investigating authority shall halt the investigation; notify immediately the OIG and the Office of the General Counsel or the Office of the Chief Counsel, as appropriate; notify the appointing official; and wait for further direction (Requirement 44620). (The safety investigation should be completed regardless of the initiation of collateral investigations.)

5.10 Release the Mishap Site and Restore Site Operations

5.10.1 Only the investigating authority shall release the mishap site for post-investigation cleanup or other activities (Requirement 44623).

5.10.2 Only the investigating authority shall release impounded data, records, equipment, or facilities (Requirement 44624).

5.10.3 The investigating authority shall not release data and records unless copies of the documents are made and retained with mishap investigation records (Requirement 44625).

5.11 Status Reports

5.11.1 For NASA Type A, Type B, and high-visibility mishaps and close calls: Every 30 work days (minimum) from the time the appointment letter is signed until the mishap investigation report is signed, the investigating authority shall develop a publicly releasable status, using the template provided on the NASA mishap investigation Web site at https://nsckn.nasa.gov and provide the signed document to the appointing official, responsible Center safety office, and the NASA Safety Center through the regional mishap support specialist.

Note: A status report is a publicly releasable document that is approved by the public affairs and legal advisors assigned to the investigating authority.

5.12 Mishap Warning-Action-Response (MWAR)

5.12.1 At any time during the investigation when the investigating authority identifies a safety finding that requires immediate action and could impact one or more Centers, the investigating authority shall develop a MWAR using the template provided on the NASA mishap investigation Web site at https://nsckn.nasa.gov and provide the signed document to the appointing official, responsible Center safety office, and the NASA Safety Center through the regional mishap support specialist.

Note: An MWAR is a publicly releasable document that is approved by the public affairs and legal advisors assigned to the investigating authority.

5.13 Distribution

5.13.1 The NASA Safety Center Mishap Investigation Support Office (MISO) will maintain the distribution list for the status reports and the MWARs, distribute the status reports and MWARs electronically, and place the MWARs on the NASA mishap investigation Web site at https://nsckn.nasa.gov and the NASA Safety Center Web site at http://nsc.nasa.gov. Status reports will be stored in the same locations as the MWAR.

Note: The NASA Safety Center distributes the status reports and the MWARs through multiple channels to ensure that the information gets to the appropriate personnel.

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