NASA Procedures and Guidelines
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NPR 8621.1C Eff. Date: May 19, 2016 Cancellation Date: May 23, 2016	NASA Procedural Requirements for Mishap and Close Call Reporting, Investigating, and Recordkeeping
| TOC | Preface | Chapter1 | Chapter2 | Chapter3 | Chapter4 | Chapter5 | Chapter6 | AppendixA | AppendixB | AppendixC | AppendixD | AppendixE | AppendixF | AppendixG | AppendixH | AppendixI | AppendixJ | AppendixK | AppendixL | AppendixM | ALL |

Chapter 1. Readiness to Conduct Investigations

1.1 NASA Mishap and Close Call Descriptions

1.1.1 A NASA mishap is an unplanned event resulting in at least one of the following:

a. Occupational injury or occupational illness to non-NASA personnel caused by NASA operations.

b. Occupational injury or occupational illness to NASA personnel caused by NASA operations.

c. Destruction of or damage to NASA property, public or private property, including foreign property, caused by NASA operations or NASA-funded research and development projects.

d. NASA mission failure before the scheduled completion of the planned primary mission.

1.1.2 A close call is an event in which there is no injury or only minor injury requiring first aid, no damage or minor damage (less than $20,000) to equipment or property or both, but which possesses the potential to cause a mishap.

1.1.3 The following situations are not considered NASA mishaps or close calls:

a. Illnesses or fatalities resulting from natural causes or those unrelated to the work environment when disease, not injury, is the cause of lost time (e.g., diabetes and resultant complications, loss of vision).

b. Intentional self-inflicted injuries or fatality.

c. Injuries or fatalities resulting from altercations, attack, assault—unless incurred in the performance of official duties such as criminal investigations—or homicide.

Note: Incidents involving personnel injured as a result of violence in the work environment will be reported to the Department of Labor in accordance with 29 CFR pt.1904.5.

d. Destruction of or damage to any property (public, private, or Government) onsite at a Center or involving NASA property on grounds outside Center property as a direct result of:

(1) Weather conditions such as hurricane, lightning, tornado, high winds, dust storm, tidal wave, tsunami, waterspout, or ice or snow loads.

Note: Damage to aircraft or hazardous conditions encountered in flight as a result of any of the above-mentioned weather conditions will be treated as a mishap or close call.

(2) Natural phenomena such as flood, landslide, earthquake, meteoroid landing, or volcanic eruption.

(3) Wild fire.

(4) Vandalism, riot, civil disorder, or felonious act such as arson or, in some cases, theft.

Note: In cases where weather, natural phenomenon, wild fire, vandalism, riot, civil disorder, or a felonious act is the proximate cause, the event is exempt from the mishap classification. However, if the weather, for example, was an intermediate cause or a contributing factor to a mishap, then this exemption to mishap classification does not apply.

Note: Damage to NASA aircraft, vehicles, or other property occurring after an aircraft or vehicle has been stolen is not reportable as a mishap. Damage to NASA aircraft, vehicles, or other property occurring when an individual misappropriates an aircraft or vehicle not authorized to be flown or driven by the individual will not be reported as a NASA mishap.

e. An intentional and controlled jettison or intentional and controlled release during flight of canopies, cargo, doors, drag chutes, hoist cables, hatches, life rafts, auxiliary fuel tanks, missiles, drones, rockets, and externally carried equipment not essential to flight when there is no injury, illness, or reportable collateral damage. In the case of missiles or drones, when the reason for jettison is not malfunction or unintentional.

f. Accidents occurring during the transportation of NASA material by commercial carriers when NASA or NASA contractors had no roles or responsibilities for packing, securing, or transporting the items.

Note: If NASA or a NASA contractor was responsible for the safety of the transport or performed any activities related to securing or transporting the material, the incident should be evaluated to determine if it was a NASA mishap.

g. Accidents involving aircraft operated as civil use, owned by civil operators, and accomplishing contract air missions for NASA where there is no NASA property damage or Federal employee injury.

h. For CubeSats/Deployers:

(1) Damage or loss of data involving CubeSats/Deployers (secondary payloads) or data flown on launch services procured by the NASA Launch Services Program (LSP) and that do not affect the primary mission in any manner.

(2) Damage or loss of data involving CubeSats/Deployers flown on dedicated launch vehicles. CubeSats/Deployers hardware is considered experimental, and their success is not a critical factor in determining the success of the mission.

(3) Damage to or loss of CubeSats/Deployers dedicated launch vehicle hardware.

i. Damage to NASA equipment residing offsite that is leased, on bailment, or loaned to contractors, commercial airlines, other Government agencies, or foreign governments when the lessee has assumed risk of damage or loss.

j. A malfunction or failure of component parts normally subjected to fair wear and tear and having a fixed useful life less than the fixed useful life of the complete system or unit of equipment, provided both of the following are true:

(1) Scheduled preventative maintenance was performed.

(2) The malfunction or failure of the component was the only damage, and the sole action is to replace or repair that component. (This does not apply to a malfunction or failure of a component part resulting in a fatality, injury, or damage to another component or a facility.)

k. Test-induced damage is not considered a mishap if all of the following are true:

(1) The test-induced damage did not result in:

(a) Injury, illness, or fatality.

(b) Damage to public property, other Government agency property, or private property (e.g., a privately owned vehicle) regardless of the property's location.

(c) Hazardous hardware debris leaving the test cell, test chamber, protected facility, pre-determined debris field, or test range unless the release could have resulted in injury, illness, or death.

(2) The facility and test equipment functioned properly except when the facility or test equipment functionality itself is being tested as part of approved test objectives.

(3) Damage is limited to test articles or test facilities, and the risk of damage was formally documented and accepted by signature before the test. The type or general category of test-induced damage (i.e., water damage, structural failure, or thermal overload) was documented as a designed and intended or potential outcome of the test, and the risk of the test-induced damage, including related uncertainties, was formally accepted by the appropriate authority. Depending on the test, the appropriate authority may be the owner of the damaged property or the person responsible for funding replacement of damaged equipment (e.g., the owner of the test article, test support equipment, test cell, chamber, pad, or protected facility, or the range, project, or program manager).

Note: Refer to Appendix C for more information on test-induced damages.

1.2 Mishap Preparedness and Contingency Plans

1.2.1 Mishap Preparedness and Contingency Plans (MPCPs) shall address the following elements:

a. An expiration date not to exceed five years from the effective date.

b. Organizational responsibility for establishing mishap investigations.

c. Notification, reporting, investigating, recording, and preparedness policies and procedures for local and offsite mishaps and close calls.

Note: This includes, but is not limited to, contact information for the offices, individuals, or both with responsibility for performing required tasks listed in this NPR. Required tasks can include, for example, contacting the NASA Office of Safety and Mission Assurance (OSMA) after a mishap; gathering resources and securing a facility; placing reports in the NASA Mishap Information System (NMIS); maintaining required data in this system; and retaining hardcopy records.

Note: Project MPCPs for aircraft operations need not address flight operations of three days or less for cross-country sorties or short campaigns.

d. The relationship between the Center Emergency Management Plan, the Center MPCP, and any related Program/Project MPCPs and which plan takes precedence given specific conditions.

Note: Communication with local emergency responders regarding imminent danger and immediate response should be addressed in the Center Emergency Management Plan.

e. The frequency interval for mishap response simulations covered by the Center MPCP and the Program/Project MPCP.

f. Training requirements for an Interim Response Team (IRT) and Investigating Authority (IA) members consistent with paragraph 1.4 of this NPR.

g. Procedures to deploy an IRT.

Note: A NASA Federal employee will serve as IRT lead (cognizant safety representative) and impound coordinator and will initiate collection of witness statement documentation. Even as these duties may not require immediate presence at the mishap scene, they nevertheless include accountability for collected and preserved evidence.

h. The impoundment process for records and equipment that may be involved in the mishap including:

(1) A list of organizations authorized to impound such evidence and secure onsite at a Center and offsite mishap locations.

(2) The location where impounded data, records, and equipment, including electronic media, are stored and secured during an investigation of either onsite at a Center or offsite mishaps.

(3) Steps for release of impounded data, records, equipment, facilities, and mishap site.

i. The appointment of an IA—a Mishap Investigator (MI), Mishap Investigation Team (MIT), or Mishap Investigation Board (MIB).

j. Delegation of authority and resources, including funding and funding organizations, for assigned IRT and potential IA members so they may expeditiously deploy to the mishap scene; effectively preserve mishap evidence; interview witnesses; and conduct an orderly investigation without administrative delay. Resources include, but are not limited to, travel, contractual authority, salaries, facilities, computer equipment, video equipment, and supplies.

k. Funding for the IRT or IA, advisors, consultants, interviewee travel, laboratory analysis, and others' support required by the IA.

l. Access to support and experts who can facilitate the immediate support, acquisition, or purchase of products needed by the IRT or IA (e.g., high-resolution cameras, recording devices, software, and others).

m. Mishap investigation report approval process for Center-processed Types C, D, and close call mishaps.

n. Medical jurisdiction for fatalities that may occur on NASA property.

Note: NASA Office of the General Counsel and local coroner may need to be consulted to determine jurisdiction and arrangements for forensic analysis.

Note: Certain religious denominations forbid autopsies.

o. Center Director (CD) or Executive Director, Office of Headquarters (HQ) Operations (ED/OHO) next of kin notification regarding fatalities and injuries. Only the Johnson Space Center CD will do astronaut next of kin notification.

p. Headquarters Office of Communications (OCOM) notification of the public for casualties, performed in accordance with local CD or ED/OHO protocols, involving NASA employees or military and other Federal personnel, including astronauts, detailed to NASA.

1.2.2 Center MPCPs, for NASA aircraft owned by NASA Centers, in addition to the elements listed in section 1.2.1, shall describe the NASA response to incidents for all flights within the local flying area and cross county flights that occur for three or fewer days' absence from the home Center.

1.2.3 Program/Project MPCPs shall address the following elements in addition to those listed in section 1.2.1:

a. Special procedures for emergency response personnel and the program/project IRT that are not covered in the Center MPCP or Center Emergency Management Plan (e.g., identification and handling of hazardous materials unique to the project).

b. Existing memoranda of agreement with international, national, State, and local organizations and agencies that may be used during a mishap investigation.

c. Critical program/project milestones upon which contingency plan implementation may be necessary. Examples may include, but are not limited to, manufacture and testing activities, launch operations, mid-course corrections or in-situ vehicle maintenance, crew loss or debilitation, approach and landing operations, or loss of mission objectives.

Note: When there are reasonable prospects for promptly recovering on-orbit or extraterrestrial from the undesired event, multiple attempts to enact planned and unplanned contingencies may be attempted prior to declaring a mishap.

d. Investigation and debris collection process required for any mishap or close call occurring in or out of the country.

e. International, national, State, and local organizations and agencies that are most likely to take part in debris collection; identification of roles and responsibilities for each organization; and points of contact.

f. Bilateral or multilateral agreements procedures for mishap investigation when the program involves international partners, program managers, and project managers.

g. Other Government agencies' resources possibly needed during a Type A or Type B mishap or high-visibility mishap or close call (Table A) investigation; points of contact and contact information for each of these agencies; procedures to acquire agency assistance; and probable roles and responsibilities for each agency (e.g., Federal Emergency Management Agency [FEMA], National Transportation Safety Board [NTSB], Department of Defense, Federal Aviation Administration [FAA], or Department of Justice).

h. The names of key personnel from NASA OCOM and the Office of International and Interagency Relations (OIIR) to be notified for all Type A and Type B mishaps.

i. For NASA aircraft owned by NASA Centers, the NASA response to incidents during project missions regardless of duration or distance away from the home Center.

1.3 Roles and Responsibilities

Note: The Administrator, Deputy Administrator, Associate Administrator (AA), Associate Administrator for the Office of International and Interagency Relations (AA/OIIR), Associate Administrator for the Office of Communications (AA/OCOM), and the Office of the General Counsel have unique responsibilities for international mishaps and contingencies, as specified in section 2.2.4.

Note: OCOM, AA/OCOM, CD, Center PAO, and ED/OHO have unique responsibilities for the release of public information, as specified in section 2.2.5.

1.3.1 CD and ED/OHO shall develop the Center MPCP and include the content specified in section 1.2. The CD and ED/OHO are responsible for funding and supporting Center MPCPs in conformance with this NPR. This includes requirements to notify, report, investigate, and record mishaps and close calls that fall within CD and ED/OHO jurisdiction. The CD and ED/OHO (or delegate) are the approval authority for Center MPCPs.

1.3.2 The Mission Directorate Associate Administrator (MDAA).

1.3.2.1 The MDAA is responsible for ensuring program/project managers develop and implement Program/Project MPCPs in conformance with this NPR. This includes procedures to notify, report, investigate, and record mishaps and close calls associated with programs and projects that fall under MDAA responsibility.

1.3.2.2 The MDAA is responsible for ensuring international partner joint program agreements and other Federal agency agreements incorporate the mishap and reporting elements of this NPR.

1.3.2.3 The MDAA is responsible for ensuring mishap plans are consistent and complimentary across "loosely coupled" programs.

1.3.3 The Cognizant Safety Office.

1.3.3.1 The Cognizant Safety Office shall support the development of the Center MPCP, Program/Project MPCPs for programs and projects that have activities at the Center, contract clauses, and mishap investigation training.

1.3.3.2 The Cognizant Safety Office shall ensure Center employees are familiar with the roles and responsibilities, as documented in the Center MPCP and this NPR, and that IRT and IA personnel complete the training required in section 1.4.

1.3.3.3 The Cognizant Safety Office shall review and provide concurrence that all program/project plans include any required program-/project-specific information and procedures not covered in the Center's MPCP (e.g., special procedures for safing, handling, or containing hazardous chemicals present in program or project hardware).

1.3.3.4 The Cognizant Safety Office shall maintain an updated list of all Center personnel who have training and experience in mishap investigation including information such as relevant training courses, dates of training, and recent participation in a mishap investigation.

1.3.3.5 The Cognizant Safety Office shall forward copies of Center and Program/Project MPCPs to the OSMA Mishap Investigation Program Executive as soon as the plans are approved.

1.3.4 The Program/Project Manager.

1.3.4.1 The Program/Project Manager is responsible for the implementation and funding of the Program/Project MPCP in coordination with applicable Centers' MPCPs and with the appropriate NASA HQ Offices, which include, at a minimum, MDAA, General Counsel, OSMA, OCOM, and OIIR, before its final approval.

Note: Program approval of NASA spaceflight Program/Project MPCPs is required prior to each project's applicable readiness review as defined in NPR 7120.5.

1.3.4.2 The Program/Project Manager shall develop the Program/Project MPCP and include the content specified in section 1.2. This includes requirements to notify, report, investigate, and record mishaps and close calls that fall within Program/Project jurisdiction.

1.3.5 The Office of Procurement.

1.3.5.1 The Office of Procurement is responsible for incorporating applicable mishap and close call reporting and investigating procedures and corrective action requirements detailed in the NFS 1852.223-70 Safety and Health into contracts, agreements, and grants covering NASA programs and operations.

1.3.5.2 The Office of Procurement shall consult the cognizant Safety Office in the acquisition strategy planning activities for proposed contracts as detailed in NASA Federal Acquisition Regulation (FAR) Supplement (NFS) pt. 1807, Acquisition Planning.

Note: See Appendices E and F for detailed procedural and positional sequencing, respectively, for notification and investigation.

1.4 Training

1.4.1 IRT personnel training shall consist of:

a. NASA IRT Training.

(1) Center/Program/Project IRT Responsibilities.

(2) General Hazard Awareness.

(3) Go-Kit Items and Use.

(4) Securing a Mishap Site.

(5) Witness Identification.

(6) Witness Statement Collection.

(7) Drug Testing Requirements and Procedures.

(8) Evidence Impoundment and Chain of Custody.

b. NASA Mishap Investigation Process Awareness.

Note: Satisfied by SMA-002-07 Overview of Mishap Investigations; SMA-002-08 Mishap Investigation Roles and Responsibilities; SMA-002-009 Completing the Investigation and Mishap Report; and SMA-002-10 Introduction to Root Cause Analysis (valid for two years); and SMA-002-11 Interim Response Team Training

c. Local Hazard Awareness.

Note: Each Center, Program, or Project should customize personnel training to address exposure to hazards created by sources unique to local activities and conditions beyond general hazard awareness. Hazard awareness training may include, but is not limited to, blood-borne pathogens, confined space, High Crew, and hazardous materials.

1.4.2 IA Training.

Note: It is recommended that IA members complete the total training in section 1.4.2.

1.4.2.1 All IA members shall have completed training in and been tested on the NASA mishap investigation policy and process.

Note: The series of NASA online courses meets this requirement: SMA-002-07 Overview of Mishap Investigations; SMA-002-008 Mishap Investigation Roles and Responsibilities; SMA-002-009 Completing the Investigation and Mishap Report; SMA-002-11 Interim Response Team Training, and SMA-002-10 Introduction to Root Cause Analysis (within the last two years).

1.4.2.2 At least one voting member and the ex officios shall have completed training in:

a. The content of this NPR.

b. Conducting witness interviews.

c. Creating timelines; documenting facts; generating fault trees; performing barrier analysis; conducting change analysis; creating event and causal factor trees; obtaining forensic analysis; integrating evidence; determining findings; generating recommendations; and producing mishap investigation reports.

Note: SMA-SAFE-OSMA-4003 NASA Root Cause Analysis (within the last five years) meets this requirement.

1.4.2.3 Human Factors members and ex officios shall have completed training in:

a. Human Factors Mishap Investigation Principles and Practices.

Note: The online course SMA-001-07 Introduction to Human Factors in Mishap and Close Call Investigation meets this requirement for all IA members except Human Factors investigator and ex officio. Classroom training SMA-SAFE-OSMA-4004 Human Factors in Mishap Investigation, or degree equivalent, is also required for Human Factors members and ex officio (refer to b.).

b. Basic knowledge of physical and psychological processes, capabilities, skill levels, and limitations of humans, such as the science and practical application of cognitive psychology, human reliability, anthropometrics, biomechanics, and human factors engineering applications to design.

Note: SMA-SAFE-OSMA-4004 Human Factors in Mishap Investigation (within the last five years) meets this requirement. The Agency Mishap Investigation Program Executive or assignee may approve educational study or degree in Human Factors as equivalent.

1.4.2.4 The Safety member shall have completed training in maintaining the security of the mishap site.

1.4.2.5 All advisors and voting members shall have technical knowledge and completed training in areas required to support the IA.

Note: Refer to Appendix D for a summary of Mishap Required Training.

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