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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 | | |||||
6.1.1 The investigating authority shall develop a mishap report that contains the information as specified in paragraph 1.7 and Figure 5 in this NPR (Requirement 44628).
6.1.2 Witness statements, witness names, and names of those involved in the mishap or related activities shall not be included as a part of the mishap report (Requirement 44629).
6.1.3 The mishap report shall be technically accurate; properly documented; easily understood; have traceability between facts, findings, and recommendations; and include the products required in Figure 5 in this NPR, in the following order:
a. Section 1: Signature page(s), list of consultants, executive summary, and OSHA summary (when applicable) (Requirement 44631).
Note: The OSHA summary goes in Section 1. The OSHA 301 Form or equivalent should be placed in the Appendix rather than Section 1 with the summary.
b. Section 2: Narrative description and facts (what, when, where, how) (Requirement 44632).
c. Section 3: Type of data gathered and data analysis (level of detail and products dependent upon Figure 5 in this NPR) (Requirement 44633).
d. Section 4: Finding(s) (Requirement 44634).
e. Section 5: Recommendation(s) (Requirement 44635).
f. Section 6: Minority Report(s) (Requirement 44636).
6.1.4 The investigating authority shall include the mishap classification level (e.g., Type A, Type B, Type C, Type D, or close call) and the IRIS/NAARS case number, the incident date, and the report date on the mishap report title page and the report executive summary (Requirement 44637).
Note: Both the Root Cause Analysis Tool and the IRIS "PRINT" function (from the Safety Incident General Tab) provide this information on the title page.
6.1.5 The investigating authority shall describe, in the mishap report, the type of property damage, type of the mission failure, and/or describe the personal injury(ies)/illness/(es) (Requirement 44638).
6.1.6 The investigating authority shall describe, in the mishap report, the actual direct cost of the mishap or if the actual direct cost is not available, the estimate of the direct cost of the mishap (Requirement 44639).
6.1.7 In the event that the investigating authority does not reach agreement on findings or recommendations, any member may develop and attach a minority report to the mishap report.
6.1.8 If the investigating authority would like to receive a preliminary review of the mishap report and feedback concerning the adequacy of the report, they may provide a draft mishap report to the appointing official and request a preliminary review.
a. This preliminary review must occur within the time allocated for the completion of the mishap report (Requirement 44642).
b. Upon receipt of a draft mishap report, the appointing official shall determine the appropriate preliminary review process and reviewing offices that should participate in the preliminary review, have them review the draft mishap report, and provide feedback to the investigating authority within 15 workdays (Requirement 44643).
c. The Center safety office or OSMA (dependent on level of investigation) shall participate in all preliminary reviews (Requirement 44644).
d. Feedback from reviewers may include, but is not limited to, requests for clarification, additional facts, further root cause analysis (or other analysis), feasibility evaluation of recommendations, compliance with NPR, and/or removal (or placement in a nonreleasable appendix) of privileged or proprietary information, ITAR information, EAR information, material subject to the Privacy Act, or other inappropriate information (i.e., witness names).
e. The chairperson and/or investigating authority is not required to make any changes to the mishap report with which he or she does not agree (Requirement 44646).
6.1.9 All investigating authority members shall sign the completed mishap report (Requirement 44647).
6.1.10 The ex officio shall sign the completed mishap report attesting to the following:
a. The investigation was conducted in conformance with NASA policy and this NPR (Requirement 44649).
b. The investigation process was fair, independent, and nonpunitive (Requirement 44650).
c. The mishap report contains all the required elements (Requirement 44651).
d. The mishap report accurately identifies the proximate cause(s), root cause(s), and contributing factor(s) (Requirement 44652).
e. Adequate facts have been gathered and analyzed to substantiate the findings (Requirement 44653).
f. The recommendations reasonably address the causes and findings (Requirement 44654).
g. Each recommendation is associated with (traceable to) at least one significant finding (Requirement 44655).
Note: Each finding does not require a recommendation except as required in paragraph 5.8.1.
h. If these conditions have not been met, the ex officio shall describe the mishap report's deficiencies in writing and sign and attach this description to the mishap report in lieu of signing the report (Requirement 44656).
6.1.11 Each NASA advisor shall sign the mishap report stating that he/she has reviewed the mishap report, that it meets NASA policies and procedures in his/her functional area (Requirement 44657) and:
a. The export control advisor's signature indicates that any ITAR information and EAR information has been identified and marked as non-releasable to the public (e.g., NASA Sensitive But Unclassified) (Requirement 44658).
b. The contracting officer's signature indicates that any proprietary information or material subject to the Privacy Act has been identified and marked as non-releasable to the public (e.g., NASA Sensitive But Unclassified) (Requirement 44659).
c. The legal advisor's and public affairs advisor's signature indicates that any privileged or proprietary information, ITAR information, EAR information, or material subject to the Privacy Act has been identified and marked as nonreleasable to the public (e.g., NASA Sensitive But Unclassified); and that volumes/appendices that are releasable to the public are marked releasable (Requirement 44660).
Note: Although marked, this release is pending endorsements and Public Affairs Office authorization.
6.1.12 The names of the consultants may be listed in the mishap report; however, the consultants shall not sign the mishap report (Requirement 44662).
6.1.13 Within 75 workdays of the mishap or close call, the investigating authority shall submit the completed and signed mishap report to the appointing official (Requirement 44663).
Note: Until this report has been signed and is officially endorsed by the endorsing officials, it is not an "official NASA Mishap Report" and should not be distributed to anyone other than the investigating authority, appointing official, endorsing officials, their reviewers, and the Headquarters SMA Mishap Coordinator.
6.1.14 If the investigating authority needs additional time to complete the investigation and/or the mishap report, they may submit a verbal or written request to the appointing official.
Upon receiving the signed mishap report, verifying that the mishap report fulfills the requirements of the appointment letter, and verifying that all records retention activities have been completed, the appointing official shall inform the investigating authority that they have fulfilled their requirements and are released from duty (Requirement 44666).
6.3.1 Upon receipt of the signed mishap report, the appointing official shall request the appropriate officials to review and endorse the mishap report (see Figure 5 of this NPR for endorsing officials) (Requirement 44668).
6.3.2 The review and endorsement process should verify, at a minimum, the following:
a. The mishap report content is technically accurate and complete (Requirement 31461).
b. Proper analysis techniques were selected and completed correctly (Requirement 31462).
c. The mishap report adequately describes proximate cause(s), root cause(s), and contributing factor(s) (Requirement 31463).
d. There are adequate facts to substantiate the findings (Requirement 31464).
e. Recommendations are associated with (traceable to) at least one significant finding (Requirement 31465).
Note: Each finding does not require a recommendation except as required in paragraph 5.8.1.
f. Recommendations are practical, feasible, achievable, and will, in the opinion of the reviewer, prevent recurrence of similar mishaps or close calls (Requirement 31466).
g. Proprietary information, ITAR information, EAR information, material subject to the Privacy Act, or privileged information that should not be released has been identified (Requirement 31467).
6.3.3 For those mishap or close call reports where the Chief/OSMA is an endorsing official, all endorsements shall be forwarded to OSMA for review prior to completion of the Chief/OSMA endorsement (Requirement 44677).
6.3.4 Within 30 workdays, the endorsing officials will provide their signed endorsement, recommendation for mishap report approval or rejection, and (when applicable) comments related to amplification or disagreement with elements of the report to the appointing official. (These endorsements and comments (when applicable) shall be attached to the mishap report and become part of the permanent record) (Requirement 44678).
6.3.5 Within 5 workdays, the appointing official shall attach all endorsements and comments (including his/her own) to the mishap report, review the comments, and determine if the report is approved or rejected based on the review and comments/direction from endorsing officials (Requirement 44679).
6.3.6 If the appointing official rejects the mishap report, he/she must provide a written description of the deficiencies that warrant this rejection, attach this to the mishap report, send the report to the Center safety office (or OSMA for Type A mishaps, Type B mishaps, high visibility mishaps, and high-visibility close calls) for records retention, and charter a new investigation (Requirement 44680).
6.4.1 If the mishap report is approved, the appointing official shall immediately send the approved report with endorsements/comments to the Export Administrator, the Center PAO, Office of Protective Services, and then to OPA, Procurement, and legal counsel for review (Requirement 44682).
Note: For Type D mishaps and Close Calls, the Center Director, via documentation in the Center Mishap Preparedness and Contingency Plan, may allow the authorization for public release to occur only after a Freedom of Information Act (FOIA) request is made. However, this does not negate the responsibility to place lessons learned into the lessons learned information system.
6.4.2 Within 10 workdays of the request, the Export Administrator, OPA, Office of Protective Services, Procurement, and legal counsel shall review the mishap report and specify in writing which sections of the mishap report are authorized for public release (Requirement 44684).
Note: The Office of Protective Services role is to review the report to determine if any information in the report should be classified Secret or Top Secret.
6.5.1 Upon receipt of notification that the mishap report is authorized for public release, the appointing official shall send the approved mishap report with authorization comments to OSMA/SARD and the Center safety office (dependent upon level of investigation) (Requirement 44687).
6.5.2 Within 10 workdays, the MDAA or the Center safety office shall distribute the mishap report to the appropriate NASA programs and organizations including, but not limited to, the responsible organization and/or program, all Center safety offices, the CHMO (when an injury or fatality has occurred), and AD (when the mishap involved an aircraft) (Requirement 44688).
6.5.3 Within 15 workdays, the Center safety office shall distribute information about the Type A mishap or Type B mishap via "weekly safety highlights" (or equivalent) to Center personnel, including a brief description of what caused the mishap and how it can be prevented (Requirement 44689).
6.5.4 The AA/OPA shall determine whether a mishap report, whatever its origin, shall be issued from Headquarters or the Center (Requirement 44690).
6.5.5 Generally, the appropriate public affairs officer shall make the news release on the mishap report available simultaneously at Headquarters and the appropriate Center (Requirement 44691).
6.5.6 The appropriate public affairs officer shall make the mishap report available to the public at the same time (Requirement 44692).
6.5.7 For aircraft mishaps, final submittal of the NASA mishap reports to the NTSB will be made by the Office of Institutions and Management. The Office of Institutions and Management will ensure that the NTSB submission meets the essential information required by the NTSB and may reformat and streamline the approved NASA report as necessary to meet that need without changing the report's causes, findings, and conclusions.
6.5.8 Within 48 hours of a mishap or close call, NASA shall provide all NASA employees and contractors access to information that is releasable to the public via a database including date, location, and brief description of the event (Requirement 44694).
6.5.9 As the mishap or close call record is updated, the employees will be given access to the updated information that is releasable to the public, including the executive summary, findings, and recommendations.
| TOC | ChangeHistory | Preface | Chapter1 | Chapter2 | Chapter3 | Chapter4 | Chapter5 | Chapter6 | Chapter7 | AppendixA | AppendixB | AppendixC | ALL | |
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