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NASA Ball NASA
Procedural
Requirements
NPR 8621.1D
Effective Date: July 06, 2020
Expiration Date: July 06, 2025
COMPLIANCE IS MANDATORY FOR NASA EMPLOYEES
Printable Format (PDF)

Subject: NASA Procedural Requirements for Mishap and Close Call Reporting, Investigating, and Recordkeeping (updated w/Change 4)

Responsible Office: Office of Safety and Mission Assurance


| TOC | ChangeHistory | Preface | Chapter1 | Chapter2 | Chapter3 | Chapter4 | Chapter5 | Chapter6 | Chapter7 | Chapter8 | Chapter9 | AppendixA | AppendixB | AppendixC | AppendixD | AppendixE | AppendixF | AppendixG | AppendixH | AppendixI | AppendixJ | ALL |

APPENDIX F. Positional Sequence for Mishap Notification and Investigation

F.1 Positional Sequence for Mishap Notification and Investigation

Positional Sequence for Mishap Notification and Investigation
Responsible Party Action NPR 8621.1D
Administrator
Appointing Official Determination
Serve as AO for Type A mishaps or delegate authority to the Associate Administrator (AA), Mission Directorate Associate Administrator (MDAA), Center Director (CD), CHMO, or other designee. 3.1.1 a.
Serve as AO for NASA joint participation on a Mishap Investigation Board (MIB) with the Department of Defense and other agencies unless otherwise specified. 3.1.1 b.
Appointing Official (AO)
Appointing Official Determination
When delegating responsibilities for Types C and D mishaps and close calls, consign formal authority to approve Investigating Authority (IA) travel, resource acquisitions, or responsible organization corrective actions. 3.1.4 d.
Investigating Authority Member Selection
Within 48 hours for Type A and Type B mishaps and high-visibility mishaps and close calls, provide a provisional list of IA appointees to the Office of Safety and Mission Assurance (OSMA) Mishap Investigation Program Executive. 3.2.1 a.
Within seven workdays, appoint IA members with concurrence from NASA Chief, SMA, the Office of the Chief Engineer (OCE), and the Office of the Chief 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 Aircraft Management Division (AMD) for Type A and Type B mishaps and high-visibility mishaps and close calls involving aircraft. 3.2.1 d.
Determine if NASA will accept the investigation and subsequent mishap investigation report of another competent authority having jurisdiction. 3.2.1 e.
Compose the IA following requirements given in 3.2.1 f. (1) through (3). 3.2.1 f. and Table C
Recommendations Generation
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.
Investigating Authority Release
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
Mishap Investigation Report Review, Endorsement, and Approval Section
Schedule an Endorsement Review with appropriate officials to review and endorse the mishap investigation report. 5.3.1 a.
Deliver copy of mishap investigation report a minimum of five workdays prior to conducting the Endorsement Review. 5.3.1 b.
Prepare for release of the Endorsement Review Record (with ex officio assistance), which includes the elements in 5.3.5 a. through e. 5.3.6 a. through e.
Serve as final endorser and authority for acceptance or rejection of mishap and close call reports in which he or she holds the AO’s position. 5.3.7
Ensure the mishap investigation process is complete. Verify mishap investigation report is reviewed and endorsed. 5.3.7 b. and c.
Assess the recommendations. 5.3.7 d.
If mishap investigation report rejected, provide a written description of the deficiencies and direction going forward. 5.3.7 e.
Corrective Action Plan Development
After the mishap investigation report has been endorsed, direct the responsible organization or program/project to develop a Corrective Action Plan (CAP). 6.1.1
Corrective Action Plan Review and Approval
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. 6.3.2 b.
Corrective Action Plan Monitoring and Close Out
Assess and approve any changes to the CAP. 6.5.2 a.
Send approved changes to the responsible organization and the Center 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.
Lessons Learned Development, Disposition, Submittal, and Approval
Ensure resources are provided to submit the Mishap Summary to the 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 Mishap Preparedness and Contingency Plan (MPCP). 6.6.1 a. and b.
Mishap Activities Conclusion
Submit the mishap 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 entered into the NASA LLIS. 6.7.1 a.
The AO’s mishap investigation obligations are fulfilled with the delivery of the mishap activities completion statement, and the mishap file is closed. 6.7.1 b.
Associate Administrator, Office of Communications (AA/OCOM)
Mishap Public Release of Information
Within one hour of the incident, 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, and provide instructions. 2.2.5.2 a.
With the assistance of the cognizant Safety Office, Interim Response Team (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.
Mishap Investigation Report Distribution
Determine whether a mishap investigation report, whatever its origin, is issued from Headquarters (HQ) or the Center. 5.4.4
Distribute the redacted mishap investigation report to the public only through FOIA request. 5.4.5
Associate Administrator (AA)
Initial Mishap Notifications
Notify the Administrator, Deputy Administrator, the Associate Administrator, Office of Communications (AA/OCOM), the Office of the General Counsel, and other appropriate staff that an international mishap has occurred. 2.2.4.4
Mishap Investigation Report Review, Endorsement, and Approval Section
Serve as endorsing official for all mishaps in which he or she is the AO. Table E.
Center Chief of Flight Operations
Aircraft Mishaps and Close Calls
Immediately notify the National Transportation Safety Board (NTSB) of the NTSB-defined mishap, and, then, advise OSMA and Aircraft Management Division (AMD) that the NTSB has been informed. 1.2.2
Within ten workdays of an aircraft mishap or close call that meets the reporting requirements in 49 CFR pt. 830, submit an NTSB Form 6120 to the NTSB regional office closest to the location of the mishap or close call. 1.2.3
Center Director (CD)/Associate Administrator, Mission Support Directorate (AA, MSD)
Roles and Responsibilities
Implement and fund the Center MPCP, including the mishap reporting, investigating, and recordkeeping requirements that fall under CD and AA, MSD responsibility. Be the approval authority or delegate appropriately for Center MPCPs. 1.3.1
Develop the Center MPCP and include the content specified in section 1.3. The CD and AA, MSD 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 AA, MSD jurisdiction. 1.4.1.1
Initial Mishap Response
Report by telephone or e-mail to the Administrator and CHMO of a work-related fatality or serious injury or illness of a Federal employee or contractor employee working on a NASA operation. 2.1.7
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.
Mishap or Close Call Classification
Within 24 hours, determine mishap classification level for all mishaps within the MDAA's jurisdiction and for which the Center has reporting responsibility and obtain concurrence on classification level from the Chief, SMA for Type A and Type B mishaps and high-visibility mishaps and close calls. 1.2.2
Mishap Public Release of Information
In initial announcements, include what is known at the time, the injuries or fatalities that have occurred, and when additional information is expected to be available. 2.2.5.4 b.
For resident contractor and grantee employee casualties, release information (within one hour) regarding the occurrence of and facts about a Type A injury or illness mishap occurring on a Center or at HQ or involving a NASA-managed program administered by the Center. 2.2.5.5
Mishap Notifications
Within 24 hours of leaning of a Type A or Type B mishap, report, by telephone or e-mail, to the Administrator. 2.3.1
[All personnel governed by this NPR] Notify the OIG and the Center's Office of the Chief Counsel or the HQ Office of the General Counsel of facts potentially related to criminal activity. 2.3.2
Appointing Official Determination
Serve as the AO (if designated by the Administrator) for Type A and Type B mishaps and high-visibility mishaps and close calls that occur onsite at a Center, at offsite Center support contractor locations, or at Center-managed offsite contractor locations that are not part of an MDAA program or project activity. 3.1.4 a.
Serve as the AO (or otherwise authorize in the Center MPCP for Type C and Type D mishaps, and close calls that occur onsite at a Center, at offsite Center support contractor locations, or at Center-managed offsite contractor locations that are not part of an MDAA program or project activity. 3.1.4 b.
When delegating AO responsibilities for Type C and D mishaps and close calls, consign formal authority to approve IA travel, resource acquisitions, or responsible organization corrective actions. 3.1.4 c.
When identifying a position to act with AO authority, formally designate that position within the Center MPCP and confer full AO authority upon that position. 3.1.4 d.
Center Office of Protective Services (OPS)
Initial Mishap Response
Support the incident commander, cognizant Safety Office, and IRT to secure the mishap site and impound data, records, equipment, and facilities. 2.1.4
Center Office of the Chief Counsel
Mishap Notifications
[All personnel governed by this NPR] Notify the NASA Office of the General Counsel of facts potentially related to criminal activity in connection with a mishap. 2.3.2
Center Procurement Office
Readiness to Conduct Investigations
Involve the Center Safety Office in the acquisition strategy planning activities for proposed contracts as detailed in 48 CFR , NFS pt. 1807. 1.4.5.2
Incorporate 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. 1.4.5.1
Center Public Affairs Office (PAO)
Mishap Public Release of Information
Before an IA is appointed and in concurrence with AA/OCOM, identify and disseminate factual, mishap-related, and suitable preliminary information to the public. Announce to the public that a fatality or injury (permanent disability) has occurred to a NASA employee involved in a Center work-related activity. 2.2.5.3 a. and b.
In the case of Federal fatalities, release victim names at the earliest possible time after CD or AA, MSD, and AA/OCOM concurrence that next of kin notification has been accomplished with CD or AA, MSD protocols. 2.2.5.4 a.
Center Responsible Organization (or Program/Project Manager)
Initial Mishap Notifications
Calculate the direct cost of a mishap or close call with review and concurrence of the Center Safety Office. 1.2.4
Corrective Action Plan Development
Within 15 workdays of tasking CAP to close out, develop and submit CAP to the AO for approval and then implementation. (See section 6.2 for CAP contents.) 6.1.2
Corrective Action Plan Implementation
Implement the corrective actions. 6.4.1 a.
Track the corrective action performance and completion in the NASA Mishap Information System (NMIS) and provide the AO with a status at intervals determined by him or her. 6.4.1 b.
Corrective Action Plan Monitoring and Close Out
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.
Lessons Learned Development, Disposition, Submittal, and Approval
[Individual or team tasked to develop lessons learned] Generate lessons learned comprising, at a minimum, the mishap investigation report’s executive summary, findings, and recommendations authorized for public release. 6.6.2 a.
Within ten workdays of being tasked, submit prepared lessons learned to the AO. 6.6.2 b.
Center Safety Office and Mission Assurance Directorate
Readiness to Conduct Investigations
Support the development of the Center MPCP, Program/Project MPCPs, contract clauses, and mishap investigation training. 1.4.3.1
Ensure Center employees are familiar with the roles and responsibilities as documented in the Center MPCP and this NPR. 1.4.3.2
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) 1.4.3.3
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. 1.4.3.4
Forward copies of Center and Program/Project MPCPs to the OSMA Mishap Investigation Program Executive as soon as the plans are approved. 1.4.3.5
Chief Engineer
Mishap Investigation Report Review, Endorsement, and Approval
Serve as an endorsing official for Type A and Type B mishaps and high-visibility mishaps and close calls. Table E.
Cognizant Safety Office
Initial Mishap Response
Upon notification of a mishap or close call that triggers the initiation of the MPCP, initiate the Center MPCP and support the program/project as the Program/Project MPCP is initiated. 2.1.2 a.
Deploy the IRT to support the investigation in accordance with the Center or Program/Project MPCPs. 2.1.2 b.
Assist the IRT with the collection of witness statements (Federal employees only). 2.1.2 c.
Initial Mishap Notifications
After emergency response has been initiated and within one hour of a 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 HQ After Hours Contact Center at 1–202-358-1414 (and provide required information). 2.2.2 a. and b.
For Type A and Type B mishaps and high-visibility mishaps and close calls, send an electronic notification to OSMA containing information found in section 2.2.2 b. 2.2.2 c.
Within one hour 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 1800.1. 2.2.2 d.
Report to the Occupational Safety and Health Administration (OSHA) in accordance with 29 CFR pt. 1904. 2.2.2 e.
After notifying OSHA, inform OSMA that an oral report has been provided to OSHA. 2.2.2 f.
Mishap Notifications
Within 24 hours of notification, ensure all NASA mishaps and close calls are initially recorded in NMIS 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. 2.3.3.1
Mishap Investigation Report Development
Upload the report to the NMIS. 5.1.6 and Appendix H
Mishap Investigation Report Distribution
After release by the NSC, distribute the Mishap Summary to the appropriate NASA programs and organizations. 5.4.3
Ensure the information recorded in NMIS is updated. 5.4.7
Correction Action Plan Implementation
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 actual direct cost is not available. 6.4.2 b.
Corrective Action Plan Monitoring and Close Out
Track corrective action activities to verify they are carried out according to plan and report non-compliance to the AO. 6.5.3 a.
Verify corrective actions activities were implemented, completed, and closed. 6.5.3 b.
Notify the AO that actions have been implemented, completed, and closed. 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.
Evidence Recording and Retention
Retain physical mishap evidence for two years from the date of the 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 suitably dispose CAP, lessons learned, and witness statements, and other documentation in accordance with NPR 1441.1. 6.8.5
Employees
Initial Mishap Response
If the situation warrants, notify emergency response (911 or designated emergency contact). 2.1.1 a.
Complete witness statements upon request of emergency response or IRT personnel. 2.1.1 b.
Initial Mishap Notifications
Report an aircraft mishap or close call, including an NTSB-defined mishap, to the cognizant Safety Office and the Center Chief of Flight Operations. 1.2.1
Endorsing Officials
Mishap Investigation Report Review, Endorsement, and Approval
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 are 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, International Traffic Arms Regulations (ITAR), or Export Administration Regulations (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
Ex Officio
Investigating Authority Member Selection
Participate in all investigation proceedings. 3.2.4 a. and b.
Assure the investigation conforms to NASA policy and this NPR and the investigation process is fair, independent, and non-punitive. 3.2.4 c.
Mishap Investigation Report Development
Serve as the authorized representative of the Chief, SMA. 5.1.3 a.
Sign the completed mishap investigation report for Type A and Type B mishaps and high-visibility mishaps and close calls attesting to the elements 5.1.3 b (1) through (7) of NPR. 5.1.3 b. (1) through (7)
If the previous conditions 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.
Freedom of Information Act (FOIA) Officer
Mishap Investigation Report Distribution
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
Distribute the full mishap investigation report to the public only by way of FOIA. 5.4.5
Interim Response Team (IRT)
Initial Mishap Response
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 should not 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 cognizant Safety Office, supervisors, and OPS support, collect and impound appropriate data, records, equipment, witness statements, and facilities that may be involved in the mishap. 2.1.5 d.
Initial Mishap Notifications
Notify the Center PAO about casualties, damages, and any potential hazards to the public. 2.2.3 a.
Support the 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 the earliest opportunity, advise a Federal employee’s supervisor if drug testing should be requested according to NPR 3792.1. 2.2.3 c.
At the earliest opportunity, 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.
Investigating Authority (IA)
Investigating Authority Member Selection
Have primacy over other Agency collateral investigations with the exception of the OIG criminal investigations. 3.2.2 a.
Consist of an odd number of voting members including the chairperson. 3.2.2 b.
Recommend membership changes to the AO regarding voting members, ex officio, and advisors. 3.2.2 c.
Does not participate in more than one type of investigation (NASA, collateral, contractor) for the same investigation or at the same time. 3.2.2 d.
Composed of a chairperson, members, and, when required, an ex officio, at a minimum. 3.2.3 a.
Have at least five members for Type A mishaps and at least three members for Type B mishaps and high-visibility incidents. 3.2.3 b.
Include a member knowledgeable in aircraft operations and maintenance or a member knowledgeable in aviation safety for all Type A and Type B mishaps and high-visibility mishaps and close calls involving aircraft. 3.2.3 c.
For Type A and Type B mishaps and high-visibility mishaps and close calls, include safety, medical, and human factors professionals as members. 3.2.3 d.
Investigating Authority Advisor Selection
For Type A and Type B mishaps and high-visibility mishaps and close calls, 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
Mishap Investigation Process Overview
Use a structured analysis technique to determine what happened, when it happened, and why it happened with the goal of preventing incident reoccurrence and similar incident occurrence. 4.1.1 a. and b.
Incident Site Safety Evidence Preservation and Impoundment
Verify the mishap site is safe and secured. 4.2.1 a.
Confirm evidence has been preserved and impounded. 4.2.1 b.
Relevant perishable evidence has been collected, photographed, and documented or impounded or both. 4.2.1 b. (1)
All necessary data, records, and equipment have been impounded and stored in a secure site. 4.2.1.b. (2)
Take custody of evidence gathered at the scene; determine status of impounded records and equipment; and develop a record of IRT, the cognizant Safety Office, emergency response, and protective services personnel actions. 4.2.1 c.
Evidence and Fact Gathering
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 mishap witnesses to determine witness observations or actions and to elicit witness opinions of possible causes of the mishap. 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.
Do not give a copy of the privileged statement to the interviewee. 4.3.3
Findings Determination Section
For Type A and Type B mishaps and high-visibility mishaps and close calls, determine the sequence of events and conditions and document them in a timeline. 4.4.1 a.
Determine relationships, supported by facts, of events and conditions to the undesired outcome. 4.4.1 b.
Provide a mishap related NASA Advisory at any time during the investigation when the IA identifies 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 Advisories approval from the IA legal and public affairs advisors or by local policy via NARS. 4.4.2.1 b.
Recommendations Generation
Develop recommendations to prevent incident reoccurrence and similar or like incident occurrence. 4.5.1 a.
Confirm the recommendations are clear, verifiable, achievable, and traceable to at least one significant finding. 4.5.1 b.
Status Reports
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 Safety and Mission Assurance (SMA) personnel through an approved distribution list. 4.6.1 b.
Post 30-day status report to the mishap record in NMIS. 4.6.1. c.
Other Investigation Types
If it is reasonably suspected a mishap resulted from criminal activity, the IA will halt the investigation; immediately notify the OIG, the AO; and the Office of the General Counsel or the Office of the Chief Counsel. 4.7.1
Mishap Investigation Report Development
Complete a mishap investigation report that contains the information as specified in Table D of this NPR in the correct order as specified. 5.1.1 a. through g. and 5.1.2 a. through g. and Table D
IA Advisors (Federal Employees)
Investigating Authority Advisor Selection
Attend meetings as needed, travel with the IA as requested, and have access to all investigative material except for privileged witness statements and interview records. 3.3.3 b.
Mishap Investigation Report Development
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
IA Chairperson
Investigating Authority Member Selection
Manage and coordinate all aspects of the mishap investigation. 3.2.5 a.
Authorize the impoundment of data, records, equipment, and facilities and collection or salvage data and debris. 3.2.5 b.
Work through the Contracting Officer with guidance from the legal advisor 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 Center public affairs advisor, and import/export control advisor throughout the investigation. 3.2.5 f.
Report only to the AO or designee during the investigation. 3.2.5 g.
Refer allegations and evidence of criminal activity identified in the course of an investigation to the OIG and General/Chief Counsel. 3.2.5 h.
Investigating Authority Advisor Selection
Include the legal advisor in deliberations that discuss privileged witness statements. 3.3.5
Mishap Investigation Report Development
Submit a request, originating with the IA chairperson, to the AO if the IA needs additional time to complete the investigation or the mishap investigation report and include the reasons for extension. 5.1.1 g.
Mishap Investigation Report Review, Endorsement, and Approval
Present the mishap investigation report and its associated findings and recommendations. 5.3.2 a.
IA Consultant
Investigating Authority Consultant Selection
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 ITAR, EAR, proprietary, or privileged information. 3.4.5
IA Legal Advisor
Investigating Authority Advisor Selection
Develop NDAs for IA contractor administrative support personnel. 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 a lawyer accompanies the interviewee during the interview process. 3.3.4 d.
Mission Directorate Associate Administrator (MDAA)
Readiness to Conduct Investigations
Ensure program/project managers develop, fund, and support Program/Project MPCPs in conformance with this NPR. This includes procedures to notify, report, investigate, and record mishaps and close calls that fall under MDAA responsibility. 1.4.2.1
Ensure international partner joint program agreements and other Federal agency agreements incorporate the mishap and reporting elements of this NPR. 1.4.2.2
Initial Mishap Notifications
Notify the AA that a mishap has occurred on foreign territory or in international waters. 2.2.4.3
Within 24 hours, determine mishap classification level for all mishaps within the MDAA’s jurisdiction and for which the Center has reporting responsibility and obtain concurrence on classification level from the Chief, SMA for Type A and Type B mishaps and high-visibility mishaps and close calls. 1.2.2
Within 24 hours of learning of a Type A or Type B mishap, report, by telephone or e-mail, to the Administrator and CHMO. 2.3.1
Appointing Official Determination
Serve as the AO for Type A mishaps, if delegated by Administrator, Type B mishaps, high-visibility mishaps, and high-visibility close calls involving Mission Directorate-managed programs, projects, and activities occurring during space flight or occurring outside Center property at MDAA program and project sites) (excluding offsite Center support contractor locations). 3.1.2 a.
Serve as the AO (or designate the responsibility in the Program/Project MPCP for Type C and Type D mishaps, and close calls involving Mission Directorate-managed programs, projects, and activities occurring during space flight or outside Center gates at MDAA program or project sites) (excluding offsite Center support contractor locations). 3.1.2 b.
Mishap Investigation Report Distribution
After NSC releases Mishap Summary, distribute it to the appropriate NASA programs and organizations. 5.4.3
NASA Safety Center (NSC), Director
Findings Determination
Distribute the mishap related NASA Advisories electronically to Agency SMA personnel through an approved distribution list. 4.4.2.2
NASA Safety Center (NSC)
Investigating Authority Advisor Selection
Support investigation activities if IA requests. 3.3.2 b.
Assist the IA chairperson and ex officio (when not named as ex officio) in consultation, preparation, and reporting. 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)
Research similar mishap findings and associated recommendations, corrective actions, and lessons learned. 3.3.2 b. (3)
Provide investigation tools and coordinate with tool specialists or necessary training. 3.3.2 b. (4)
Assess 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)
Mishap Investigation Report Distribution
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
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
Occupational Health Representative or Other Medical Person
Mishap Notifications
Provide medical information regarding injured persons and the nature of the injuries as a result of a mishap or close call to the Center Safety Office for inclusion in the investigation report and NMIS. 2.3.3.2
Office of Communications (OCOM)
Mishap Public Release of Information
Approve the release of all information related to NASA Type A and Type B mishaps and high-visibility mishaps and close calls prior to release to media or public. 2.2.5.1
Lessons Learned Development, Disposition, Submittal, and Approval (Export and Import)
Office of Inspector General (OIG)
Mishap Notifications
[All personnel governed by this NPR] Notify the NASA Office of the General Counsel of facts potentially related to criminal activity in connection with a mishap. 2.3.2
Office of Protective Services (OPS)
Initial Mishap Response
Support the incident commander, cognizant Safety Office, and IRT in securing the site and impounding data, records, equipment, and facilities 2.1.4
Chief, Safety and Mission Assurance
Appointing Official Determination
Contact the Administrator within one hour of the initial notification of a Type A mishap to determine if the Administrator wishes to exercise appointment authority. 3.1.3 a.
Concur with the mishap classification level and the IA membership and serve as an endorsing official for the mishap investigation report for Type A and Type B mishaps and high-visibility mishaps and close calls. 3.1.3 b.
If the NTSB exercises its authority to investigate a NASA aircraft mishap, [may] conduct a separate investigation. 3.1.6
Mishap Investigation Report Review, Endorsement, and Approval Section
Serve as an endorsing official for Type A and Type B mishaps and high-visibility mishaps and close calls. Table E.
Evidence Recording and Retention
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.
Office of Safety and Mission Assurance (OSMA)/Mishap Investigation Program Executive
Appointing Official Determination (on NASA's behalf)
Support investigations of NASA mishaps by other Federal agencies authorized to investigate NASA mishaps. 3.1.7 a.
Support other Federal agencies, foreign participants, and private industry mishap investigations in accordance with agreements. 3.1.7 b.
Office of Strategic Infrastructure (OSI)
Mishap Investigation Report Distribution
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
Office of Strategic Infrastructure, Aircraft Management Division (OSI/AMD)
Mishap Investigation Report Review, Endorsement, and Approval
Serve as an endorsing official for Type A and Type B mishaps and high-visibility mishaps and close calls involving aircraft. Table E.
Office of the Chief Health and Medical Officer (CHMO)
Appointing Official Determination
Serve as the AO for a Type A mishaps, Type B mishaps, high-visibility mishaps, high-visibility close calls involving a human research subject. 3.1.5 a.
Serve as the AO via the IRB process for Type C and Type D mishaps, and close calls involving a human research subject. 3.1.5 b.
Mishap Investigation Report Review, Endorsement, and Approval Section
Serve as an endorsing official for Type A and Type B mishaps and high-visibility mishaps and close calls involving injury or fatality. Table E.
Office of the General Counsel
Mishap Notifications
[All personnel governed by this NPR] Notify the NASA Office of the General Counsel of facts potentially related to criminal activity in connection with a mishap. 2.3.2
Official-In-Charge
Initial Mishap Notifications
For NASA mishaps occurring on foreign territory or in international waters, notify the Chief, SMA; the appropriate MDAA; and the cognizant Safety Office. 2.2.4.1
When a Type A or Type B mishap occurs outside the United States involving NASA personnel, the Official in Charge, in coordination with AA/OCOM and Associate Administrator, Office of International and Interagency Relations (AA/OIIR), releases factual details outlined in NPR through the U.S. Embassy or Consular Office in the locale of the mishap, in accordance with policies and procedures established by those offices. 2.2.4.2
Program/Project Manager
Readiness to Conduct Investigations
Coordinate Program/Project MPCPs 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. 1.4.4.1
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. 1.4.4.2
Initial Mishap Response
Upon notification of a mishap, initiate the Program/Project MPCP. 2.1.3
Responsible Program Manager or Organization
In coordination with the Chief Financial Officer or designee, calculate the cost of a mission failure. 1.2.4
Corrective Action Plan Development
Within 15 workdays from being tasked, submit the CAP to the AO for approval and then implementation. 6.1.2
Supervisors
Initial Mishap Notifications
Notify the Center Safety Office when a mishap or close call occurs or is suspected. 2.2.1


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