Procedural
Requirements
Effective Date: July 06, 2020
Expiration Date: July 06, 2025
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NASA Procedural Requirements |
NPR 8621.1D Effective Date: July 06, 2020 Expiration Date: July 06, 2025 |
| | TOC | ChangeHistory | Preface | Chapter1 | Chapter2 | Chapter3 | Chapter4 | Chapter5 | Chapter6 | Chapter7 | Chapter8 | Chapter9 | AppendixA | AppendixB | AppendixC | AppendixD | AppendixE | AppendixF | AppendixG | AppendixH | AppendixI | AppendixJ | ALL | |
E.1 Procedural Sequence for Mishap Notification and Investigation
| Procedural Sequence for Mishap Notification and Investigation | ||
| Timeframe | ||
| Responsible party | Action | NPR8621.1D |
| Immediately | ||
| Employees | If the situation warrants, notify emergency response (911 or designated emergency contact). | 2.1.1 a. |
| Supervisors | Notify cognizant Safety Office of occurrence or suspected occurrence of a mishap or close call. | 2.2.1 |
| Employees | Report an aircraft mishap or close call, including a National Transportation Safety Board (NTSB) defined mishap, to the cognizant Safety Office and the Center Chief of Flight Operations. | 1.2.1 |
| Cognizant Chief of Flight Operations or Designee | Notify the NTSB of NTSB-defined mishap, and then advise Office of Safety and Mission Assurance (OSMA) Mishap Investigation Program Executive and the Aircraft Management Division (AMD) that NTSB has been informed. | 1.2.2 |
| Cognizant Safety Office | Upon notification of a mishap or close call that triggers the initiation of the Mishap Preparedness and Contingency Plan (MPCP), initiate the Center MPCP and support the program/project as the Program/Project MPCP is initiated. | 2.1.2 a. |
| Deploy the Interim Response Team (IRT) to support the investigation in accordance with the Center or Program/Project MPCP. | 2.1.2 b. | |
| Program/Project Manager | Upon notification, initiate Program/Project MPCP. | 2.1.3 |
| After Emergency Response Initiated and Within 1 Hour of Mishap | ||
| Cognizant Safety Office | For Type A or Type B mishap or a high-visibility mishap or close call, notify OSMA by calling 1–443–614–7840, or if no answer, by calling the NASA Headquarters (HQ) After Hours Contact Center at 1–202-358-1414 (and provide required information). | 2.2.2 a. and b. |
| Report to the CHMO an illness or injury that results in a loss of life, permanent disability, hospitalization, extensive first aid, or lost workdays in accordance with NPR 1800. | 2.2.2 d. | |
| Center Director or AA, MSD | Report, by telephone, to the Administrator and CHMO a work-related fatality or serious injury or illness | 2.1.7 |
| Associate Administrator/ Office of Communications | Release information to the media and alert Center personnel and the public of any known hazards and their potential effects and provide instructions to mitigate the risk and harm. | 2.2.5.2 a. |
| With assistance from the cognizant Safety Office, IRT, and Center Director (CD) or AA, MSD, release interim public affairs status reports about the investigation to the media through the Center Public Affairs Office (PAO) | 2.2.5.2 b. | |
| Center Director or AA, MSD | In coordination with Center PAO and HQ Office of Communications (OCOM), for resident contractor and grantee employee casualties, release information regarding the occurrence of and facts about injury or illness mishap only for a Type A injury or illness mishap occurring onsite at a Center or at HQ or involves a NASA-managed program administered by that Center. | 2.2.5.5 |
| After Emergency Response Initiated | ||
| Cognizant Safety Office | For Type A or Type B mishaps or high-visibility mishaps or close calls, send encrypted electronic communication to OSMA. (See section 2.2.2 b.) | 2.2.2 c. |
| Report to the Occupational Safety and Health Administration (OSHA) in accordance with 29 CFR 1904. | 2.2.2 e. | |
| Inform OSMA that an oral report has been provided to OSHA. | 2.2.2 f. | |
| As Quickly as Possible (Notifications) | ||
| Official-In-Charge | For NASA mishaps occurring on foreign territory or in international waters, notify Chief, SMA, appropriate Mission Directorate Associate Administrator (MDAA), the CHMO if injury or illness related, and cognizant Safety Office. | 2.2.4.1 |
| When a Type A or Type B mishap occurs outside the United States, in coordination with the Associate Administrator, Office of Communications (AA/OCOM) and the Associate Administrator, Office of International and Interagency Relations (AA/OIIR), release factual, limited details through the U.S. Embassy or Consular Office in the locale of the mishap, in accordance with policies of that office | 2.2.4.2 | |
| Mission Directorate Associate Administrator | For NASA mishaps occurring on foreign territory or in international waters, notify the Associate Administrator (AA). | 2.2.4.3 |
| Associate Administrator | Notify the Administrator, Deputy Administrator, the AA/OCOM, the Office of the General Counsel, and other appropriate staff that an international mishap has occurred. | 2.2.4.4 |
| Headquarters Office of Communications | Approve the release of all related information for Type A and Type B mishaps and high-visibility mishaps and close calls prior to release to media or public. | 2.2.5.1 |
| Center Public Affairs Office | Before an Investigating Authority (IA) is appointed and in coordination with AA/OCOM, identify and disseminate any preliminary information, video, and imagery related to the mishap that is suitable for public release. | 2.2.5.3 a. |
| When a fatality or injury (permanent disability) has occurred to a NASA employee involved in a Center work-related activity, coordinate with AA/OCOM and, then, promptly announce the incident to the public. | 2.2.5.3 b. | |
| At Mishap Scene | ||
| Interim Response Team | Preserve potential evidence, document the scene, obtain witness statements, and collect debris. | 2.1.5 a. |
| Copies of privileged written or transcripts of verbal statements are not to be given to witnesses as privilege and confidentiality cannot be ensured. | 2.1.5 b. | |
| Conduct evidence preservation actions without affecting essential safety operations. | 2.1.5 c. | |
| With support from the cognizant Safety Office, supervisors, Center Chief Medical Officer or Medical Director, and the Center Office of Protective Services (OPS), collect and impound appropriate data, records, equipment, witness statements, and facilities that may be involved in the mishap. | 2.1.5 d. | |
| If the impacted individuals have signs or symptoms consistent with a medical malady that may have been contributory or as a result of the mishap itself, contact the flight surgeon, or medical professional, on-call for appropriate referral, testing, or disposition. | 2.2.3 e. | |
| Interim Response Team and Investigating Authority | Coordinate with the Contracting Officer before accessing site, impounding contractor data, and interviewing contractor personnel. | 2.1.6 |
| Employees | Complete witness statements at the request of emergency response or IRT personnel. | 2.1.1 b. |
| Cognizant Safety Office | Assist with witness statement collection. | 2.1.2 c. |
| Center Office of Protective Services | Support the incident commander, cognizant Safety Office, and IRT to secure mishap site and impound data, records, equipment, and facilities. | 2.1.4 |
| After Scene Is Secured | ||
| Interim Response Team | Notify Center PAO about casualties, damages, and any potential hazards to the public. | 2.2.3 a. |
| Support PAO with release of information to the media to alert Center personnel and the public of any known hazards and their potential effects. | 2.2.3 b. | |
| At Earliest Opportunity | ||
| Interim Response Team | Advise Federal employee's supervisor if drug testing should be requested according to NPR 3792.1. | 2.2.3 c. |
| Notify the Contracting Officer or Contracting Officer’s Representative if drug testing for contract personnel is to be implemented according to the contract or applicable agreements. | 2.2.3 d. | |
| Center Director or AA, MSD | [All personnel governed by this NPR] Notify NASA Office of Inspector General (OIG) and the Center's Office of the Chief Counsel or the NASA Office of the General Counsel of facts potentially related to criminal activity in connection with a mishap. | 2.5.2 |
| For Centers located on a military installation, release victim names according to procedures previously agreed upon by the installation commander and CD or AA, MSD. | 2.2.5.4 c. | |
| Cognizant Public Affairs Office | In cases of Federal fatalities, release victim names after CD or AA, MSD and AA/COM concurrence that next of kin notification has been accomplished with CD or AA, MSD protocols. | 2.2.5.4 a. |
| Within 24 Hours | ||
| Mission Directorate Associate Administrator, CHMO, Center Director, and AA, MSD or Designees | Determine the mishap classification level for all mishaps within their jurisdiction and obtain concurrence on this classification level from the Chief, SMA for Type A and Type B mishaps and high-visibility mishaps and close calls. | 2.3.2 |
| Center Director, AA, MSD, and Mission Directorate Associate Administrator | Report by telephone or e-mail to the Administrator and CHMO the instance of a NASA Type A or Type B mishap or high-visibility mishap or close call. | 2.4.1 |
| Cognizant Safety Office | Ensure all NASA mishaps and close calls are initially recorded in the NASA Mishap Information System and are updated throughout the mishap investigation. | 2.3.3.1 and Appendix H |
| Enter all information for aircraft mishaps and close calls listed in 49 CFR pt. 830, with the exception of the pilot's name, into NMIS. | 2.4.3.1. | |
| Occupational Health Representative (or Other Medical Person) | Provide the appropriate medical information regarding the persons injured and the nature of the injuries as a result of a mishap or close call to the cognizant Safety Office for inclusion in the investigation report and NMIS. | 2.4.3.2 |
| Responsible Organization | Calculate the direct cost of a mishap or close call with review and concurrence of the cognizant Safety Office. | 2.3.3 |
| Responsible Program Manager or Responsible Organization | Calculate the cost of a mission failure in coordination with the cognizant Chief Financial Officer or designee. | 2.3.4 |
| Within 48 Hours | ||
| Appointing Official | For Types A and B, and high-visibility mishaps and close calls, provide a provisional list of IA appointees to the OSMA Mishap Investigation Program Executive for concurrence. | 3.2.1 a. |
| Within 7 Workdays | ||
| Appointing Official | Appoint the members of the IA with concurrence from NASA Chief, SMA, the Office of the Chief Engineer (OCE), and the Chief Health and Medical Officer (CHMO). | 3.2.1 b., Table B, and sec. 3.5 |
| Designate the IA chairperson. | 3.2.1 c. | |
| Obtain concurrence from the AMD for Type A and Type B mishaps and high-visibility mishaps and close calls involving aircraft. | 3.2.1 d. | |
| Compose the IA. Ensure requirements are met. | 3.2.1 f. and Table C | |
| Investigating Authority | Recommend membership changes to the AO regarding voting members, ex officio, and advisors. | 3.2.2 c. |
| Within 10 Workdays of an Aircraft Mishap | ||
| Cognizant Chief of Flight Operations | When an aircraft mishap or close call meets reporting requirements in 49 CFR pt. 830, submit an NTSB Form 6120 to the NTSB regional office nearest to the location of the mishap or close call. | 2.3.3 |
| During Investigation | ||
| Investigating Authority Chairperson | Manage and coordinate all aspects of the mishap investigation. | 3.2.5 a. |
| Authorize impoundment of data, records, equipment, and facilities and collection or salvage of data and debris. | 3.2.5 b. | |
| Work with procurement and legal advisors to obtain and impound data for mishaps at contractor or subcontractor sites. | 3.2.5 c. | |
| Release impounded data, records, equipment, facilities, and mishap site when no longer necessary. | 3.2.5 d. | |
| Define the roles and areas of investigative responsibility for each group or subgroup on the IA. | 3.2.5 e. | |
| Coordinate with the IA legal advisor, HQ, or cognizant public affairs advisor, and other advisors throughout the investigation. | 3.2.5 f. | |
| Report only to the AO or designee during the investigation. | 3.2.5 g. | |
| With IA legal advisor assistance, refer allegations and evidence of criminal activity identified in the course of an investigation to the OIG and General/Chief Counsel. Privileged witness statements will be protected to the extent provided by law and all OIG requests for privileged information will be processed through HQ. | 3.2.5 h. | |
| Investigating Authority | For Type A and Type B mishaps and high-visibility mishaps and close calls, the IA will have a legal advisor and a public affairs advisor | 3.3.1 |
| Have access to a NASA Safety Center (NSC) mishap investigation specialist to assist with investigation for Type A and Type B mishaps and high-visibility mishaps and close calls. | 3.3.2 | |
| Verify the mishap site is safe and secured. Confirm evidence has been preserved and impounded. Take custody of evidence gathered at the scene. | 4.2.1 a. through c. | |
| Collect and evaluate all available data and records relevant to the mishap. | 4.3.1 a. | |
| Permit only Federal employees to be present at privileged witness interviews. (Exception: the interviewee and contractors hired to support interviews. Contractors will have signed a nondisclosure agreement (NDA). | 4.3.1 b. | |
| Interview witnesses. | 4.3.1 c. (1) and (2) | |
| Inform interviewee if the information gathered during the interview is confidential and privileged. | 4.3.1 d. | |
| When the discussion is kept privileged, read the witness statement to the interviewee. | 4.3.2 and Figure 1 | |
| Use a structured analysis technique to determine what happened, when it happened, and why it happened with the goal of preventing incident occurrence. | 4.1.1 a. and b. | |
| Provide a mishap related NASA Advisory at any time during the investigation for a safety finding requiring immediate action and could impact one or more Centers or when NASA-wide implications are present. | 4.4.2.1 a. | |
| Obtain mishap related NASA Advisory approval from the IA legal and public affairs advisors or by local policy. | 4.4.2.1 b. | |
| Investigating Advisors (Federal employees) | Attend meetings as needed, travel with the IA as requested, and have access to all investigative material. Only the legal and medical advisors may access privileged witness statements and interview records. | 3.3.3 b. |
| Investigating Authority Legal Advisor | Develop NDAs for IA contractor administrative support personnel and consultants. | 3.3.4 a. |
| Develop NDAs when the IA uses a contractor to analyze interview data or participate in interviews. | 3.3.4 b. | |
| Provide legal advice and counsel as requested by the chairperson. | 3.3.4 c. | |
| Attend interviews if the interviewee is accompanied by a lawyer during the interview process. | 3.3.4 d. | |
| Investigating Authority Consultants | Have academic and technical experience matching or exceeding the technical and management complexity of systems related to the mishap. | 3.4.2 |
| Contracted or hired to provide technical expertise to the IA; perform analysis; assist in formulating findings. | 3.4.3 a. through c. | |
| Non-Federal employee administrative support: sign an NDA before given access to mishap data or International Traffic Arms Regulations (ITAR), or Export Administration Regulations (EAR) information or proprietary, or privileged information. | 3.4.5 | |
| Ex Officio | Participate in all investigation deliberations as a non-voting member and participate in all investigation proceedings. | 3.2.4 a. and b. |
| Ensure the investigation conforms to NASA policy and this NPR and the investigation process is fair, independent, and non-punitive. | 3.2.4 c. | |
| NASA Safety Center | Ensure timely availability to support Type A and Type B mishaps and high-visibility mishaps and close calls. | 3.3.2 a. |
| Provide consultation, preparation, and reporting assistance to the IA chairperson. | 3.3.2 b. (1) | |
| Identify pertinent Agency-level audit results from other NASA installations and coordinate with associated Center representatives responding to audit findings. | 3.3.2 b. (2) | |
| Researching similar mishap findings and associated recommendations, corrective actions, and lessons learned. | 3.3.2 b. (3) | |
| Provide investigation tools and training. | 3.3.2 b. (4) | |
| Assess the root cause analysis and associated IA recommendations for clarity, verifiability, achievability, and traceability. | 3.3.2 b. (5) | |
| Assist with IA investigation endorsement. | 3.3.2 b. (6) | |
| Maintain the distribution lists for status reports (section 4.6) and mishap related NASA Advisories, and place mishap related NASA Advisories on the NASA Mishap Investigation Web site and the NSC Web site. Mishap related NASA Advisories and status reports will be co-located. | 4.4.2.3 | |
| NASA Safety Center Director | Distribute mishap related NASA Advisories electronically to Agency Safety and Mission Assurance (SMA) personnel through an approved distribution list. | 4.4.2.2 |
| Appointing Official | Assess recommendations according to their effectiveness in reducing likelihood and consequence of causal factor reoccurrence. | 4.5.2 a. |
| Communicate recommendations outside his or her authority to the responsible NASA organization or external body for implementation of corrective action. | 4.5.2 b. | |
| Every 30 Workdays During Investigation | ||
| Investigating Authority | Develop a publicly releasable investigation status report for NASA Type A and Type B mishaps and high-visibility mishaps and close calls, every 30 workdays from the time the appointment letter is signed until the mishap investigation report is signed. | 4.6.1 a. |
| Distribute the approved status report to the AO, responsible Center or Program Safety Office, NSC mishap support specialist, and Agency SMA personnel through an approved distribution list and attach the report to the case file in NMIS. | 4.6.1 b. and c. | |
| Within Specified Timeframe | ||
| Investigating Authority | Complete a mishap investigation report that contains the specified information. | 5.1.1 a. through f. and 5.1.2 a through g. and Table D. |
| Investigating Authority Chairperson | If additional time is needed to complete the investigation and/or the mishap investigation report, submit a request to the AO including the rationale for the extension. | 5.1.1 g. |
| Ex Officio | As the Chief, SMA authorized representative, sign the completed mishap investigation report for Type A and Type B mishaps and high-visibility mishaps and close calls and attest to items (1) through (7). | 5.1.3 a. and b. (1) through (7) |
| If requirements described in 5.1.3 b. have not been met, describe the mishap investigation report's deficiencies in writing and sign and attach this description to the mishap investigation report in lieu of signing the report. | 5.1.3 c. | |
| Investigating Authority Advisors (Federal Employees) | Sign the mishap investigation report for Type A and Type B mishaps and high-visibility mishaps and close calls stating that the report meets NASA policies and procedures in the advisor’s functional area. | 5.1.4 |
| Cognizant Safety Office | Upload the report to NMIS. | 5.1.6 and Appendix H. |
| Appointing Official | Verify completed mishap investigation report for Type A and Type B mishaps and high-visibility mishaps and close calls fulfills the appointment letter’s and this NPR’s requirements, and release the IA from duty. | 5.2 |
| Schedule an Endorsement Review with appropriate officials to review and endorse the mishap investigation report and deliver a copy of the mishap investigation report a minimum of five workdays prior to conducting the Endorsement Review. | 5.3.1 a. and b. and Table E. | |
| At Endorsement Review and Out Brief | ||
| Investigating Authority Chairperson | Present the mishap investigation report and its associated findings and recommendations at out brief. | 5.3.2 a. through d. |
| Endorsing Officials | Verify the mishap investigation report content is technically correct and complete. | 5.3.3 a. |
| Concur/nonconcur the mishap investigation report describes causal and contributing factors. | 5.3.3 b. | |
| Concur/nonconcur that the recommendations as practical, feasible, achievable, and in the opinion of the reviewer, will prevent the occurrence of similar mishaps or close calls. | 5.3.3 c. | |
| Concur/nonconcur that proprietary, ITAR, or EAR information; material subject to the Privacy Act; or privileged information has been properly identified and protected. | 5.3.3 d. | |
| Sign the Endorsement Review Record, signifying mishap investigation report concurrence or nonconcurrence and provide comments related to decision. | 5.3.4 | |
| Attach the Endorsement Review Record and comments to the mishap investigation report as part of the permanent record. | 5.3.5 | |
| After Endorsement Review and Out Brief | ||
| Appointing Official | With assistance from the cognizant Safety Office, prepare for release of the Endorsement Review Record. | 5.3.6 a. through e. |
| Serve as final authority for acceptance or rejection of mishap and close call investigation reports in which he or she holds the AO’s position. | 5.3.7 a. | |
| Ensure the mishap investigation process is complete; verify the mishap investigation report is reviewed and endorsed. | 5.3.7 b. and c. | |
| Assess the report recommendations. | 5.3.7 d. | |
| If rejecting the report, provide a written description of deficiencies and direction going forward. | 5.3.7 e. | |
| Cognizant or Mission Directorate Representatives | Notify the designated Freedom of Information Act (FOIA) officer that the mishap investigation report is authorized for release. | 5.4.1 |
| Freedom of information Act Officer | When notified by the Center or mission directorate representatives that the mishap investigation report is authorized for public release, send approved mishap investigation report with authorization comments to the AO, OSMA, and the Center Safety Office (dependent on level of investigation). | 5.4.1 |
| NASA Safety Center | Complete public release review and distribute the Mishap Summary for prevention awareness and other appropriate action by NASA Centers and field installations. | 5.4.2 |
| Mission Directorate Associate Administrator or Cognizant Safety Office | Distribute Mishap Summary to the appropriate NASA programs and organizations. | 5.4.3 |
| Associate Administrator, Office of Communications | Determine whether a mishap investigation report, whatever its origin, will be issued from HQ or the Center. | 5.4.4 |
| Distribute the redacted mishap investigation report to the public only through FOIA request. | 5.4.5 | |
| Office of Strategic Infrastructure | For aircraft mishap investigations delegated to NASA by NTSB, submit the approved NASA mishap investigation report to the NTSB ensuring it meets the NTSB’s required information. | 5.4.6 |
| Cognizant Safety Office | Ensure the information recorded in NMIS is updated. | 5.4.7 |
| After Report Endorsement and at the Earliest Opportunity | ||
| Appointing Official | Direct the responsible organization or program/project to develop a Corrective Action Plan (CAP). | 6.1.1 |
| Within 15 Workdays of Tasking CAP to Close Out | ||
| Responsible Organization or Program/Project Manager | Submit the CAP to the AO for approval and then implementation. | 6.1.2 |
| Appointing Official | Review and accept or reject the CAP. | 6.3.2 a. |
| Return a rejected CAP with comments to the responsible organization or program/project for revision and resubmission. | 6.3.2 b. | |
| Responsible Organization | Implement CAP and track performance. | 6.4.1 a. and b. |
| Update the cognizant Safety Office on the status of corrective action activities at least every 30 workdays until the CAP is closed. | 6.5.1 a. | |
| Submit changes to the CAP after it has been approved to the cognizant Safety Office or Program for review. After this review, send the requested changes to the AO for approval. | 6.5.1 b. | |
| Appointing Official | Assess and approve any changes to the CAP. | 6.5.2 a. |
| Send approved changes to the responsible organization and the cognizant Safety Office. | 6.5.2 b. | |
| Once corrective actions for Type A and Type B mishaps and high-visibility mishaps and close calls are fulfilled, provide a Corrective Action Plan Closure Statement to the Center Safety Office and responsible organization advising the CAP has been closed. | 6.5.2 c. | |
| Cognizant Safety Office | Assist the responsible organization, if needed, to enter updates into NMIS as described in the Center MPCP. | 6.4.2 a. |
| Enter into NMIS the actual direct cost of the mishap or the estimated direct cost, if the actual direct cost is not available. | 6.4.2 b. | |
| Verify corrective actions activities were implemented, completed, and closed. | 6.5.3 b. | |
| Report noncompliance to or notify AO that actions have been implemented, completed, and closed. | 6.5.3 a. and 6.5.3 c. | |
| Verify the mishap investigation report, endorsements, approved CAP and Corrective Action Plan Closure Statement, and mishap activities completion statements are complete and correctly recorded in NMIS. | 6.5.3 d. | |
| Appointing Official | Ensure resources are provided to submit the Mishap Summary to the Lessons Learned Information System (LLIS) for entry for Type A and Type B mishaps and high-visibility mishaps and close calls. Lessons learned for Types C and D mishaps and close calls are developed according to the MPCP. | 6.6.1 a. and b. |
| Within 10 Workdays of Tasking (Lessons Learned) | ||
| Responsible Organization Designees | Generate lessons learned. | 6.6.2 a. |
| Submit lessons learned to AO. | 6.6.2 b. | |
| Upon Completion of Investigation | ||
| Appointing Official | Submit the investigation activities completion statement to the responsible organization, OSMA (for Type A and Type B mishaps and high-visibility mishaps and close calls), the cognizant Safety Office, and other appropriate organizations indicating the investigation was performed; the CAP was implemented, completed, and closed; and the lessons learned were entered into the NASA LLIS. | 6.7.1 a. |
| Cognizant Safety Office | Retain records and evidence for two years from the date of mishap and before disposition of physical evidence, seek concurrence from the Office of the General Counsel to confirm there is no active litigation affecting dispositional decisions. | 6.8.2 and 6.8.3 |
| Manage and dispose CAP, lessons learned, witness statements, and other documentation in accordance with NPR 1441.1. | 6.8.5 | |
| Chief, Safety and Mission Assurance or Designee | Archive HQ-approved NASA mishap investigation reports and related documents in accordance with NRRS 1441.1. | 6.8.6 a. |
| Handle and protect NASA information according to the requirements of NPR 1600.1, NPR 2190.1, and NPR 2810.1. | 6.8.6 b. | |
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