NASA logo NASA Headquarters' Directives
HQPR 8621.1
Effective Date: November 08, 2011
Expiration Date: June 08, 2019
Responsible Office: LM
Mishap Reporting, Investigating, and Recordkeeping Program and Plan
[<< back <<]

This document is uncontrolled when printed.
Check the NASA Online Directives Information System (NODIS) Library
to verify that this is the correct version before use.

Table of Contents | Preface | Chapter1 | Chapter2 | Chapter3 | Chapter4 | Chapter5 | Chapter6 | Chapter7 | AppendixA | AppendixB | AppendixC | AppendixD | AppendixE | AppendixF | Appendix G | AppendixH | AppendixI | AppendixJ | AppendixK | AppendixL

APPENDIX A: Terms and Definitions

A.1 Appointing Official. The official authorized to appoint the Investigating Authority for a mishap or close call, to accept the investigation of another authority, to receive endorsements and comments from endorsing officials, and to approve the mishap report.

A.2 Cause. An event or condition that results in an effect. Anything that shapes or influences the outcome.

A.3 Close Call. An event in which there is no injury or only minor injury requiring first aid and/or no equipment/property damage or minor equipment/property damage (less than $1,000),but which possesses a potential to cause a mishap.

A.4 Contributing Factor. An event or condition that may have contributed to the occurrence of an undesired outcome but, if eliminated or modified, would not by itself have prevented the occurrence.

A.5 Corrective Action Plan (CAP). A plan developed to address each finding of the mishap investigation to a level to prevent, minimize, or limit the potential for recurrence of a mishap.

A.6 CAP Closure Statement. A final statement made by the appointing official that documents that all corrective actions have been completed and the CAP is closed.

A.7 Corrective Actions. Changes to design processes, work instructions, workmanship practices, training, inspections, tests, procedures, specifications, drawings, tools, equipment, facilities, resources, or material that result in preventing, minimizing, or limiting the potential for recurrence of a mishap.

A.8 Direct Cost of Mishap or Close Call (for the purpose of mishap classification). The sum of the costs (the greater value of actual or fair market value) of damaged property, destroyed property, or mission failure, actual cost of repair or replacement, labor (actual value of replacement or repair hours for internal and external/contract labor), cost of the lost commodity (e.g., the cost of the fluid that was lost from a ruptured pressure vessel), as well as resultant costs such as environmental decontamination, property cleanup, and restoration, or the best official estimates of these costs.

A.9 Endorsing Official. An Official who reviews the signed mishap report and provides a signed written endorsement, comments (when applicable), and a recommendation for approval or rejection of the mishap report.

A.10 Ex Officio. An individual authorized to participate in all investigation proceedings and tasked to ensure that the investigation is conducted in conformance with NASA and HQ requirements.

A.11 Event. A real time occurrence describing one discrete action, typically an error, failure or malfunction. Examples: pipe broke, power lost, or person opened valve.

A.12 First Aid. Any one-time treatment of minor scratches, cuts, burns, splinters, etc., which does not ordinarily require medical care, and any follow-up visit(s) for the purpose of observation. Such one-time treatment and follow-up visit(s) for the purpose of observation are considered first aid even though provided by a physician or registered professional. Refer to 29 CFR Part 1904.7(b) (5) (ii) for a complete definition.

A.13 High-Visibility Incident (Mishap or Close Call). Those particular mishaps or close calls, regardless of the amount of property damage or personnel injury, that the NASA Administrator, NASA Chief/Office of Safety and Mission Assurance (OSMA), Executive Director (ED), or Assistant Administrator, Mission Support Directorate (AA/MSD), judge to possess a high degree of programmatic impact or public, media, or political interest, including, but are not limited to, mishaps and close calls that impact flight hardware, flight software, or completion of critical mission milestones.

A.14 HQ Safety Office IRIS Representative. An individual who has been trained, given an IRIS account, and given the responsibility to enter and update mishap data in the IRIS database for HQ.

A.15 Human Factors Mishap Investigator. An employee with expertise in human factors engineering and mishap causation who has the primary responsibility to assist in the collection and analysis of data, determine how human factors caused or contributed to the mishap or close call, evaluates relevant human error and determines its root cause (s), and generates recommendations that eliminate or reduce the occurrence of the error or minimize the negative effects of the error to prevent the recurrence of the mishap.

A.16 Incident. An occurrence of an action or situation that can result in a mishap or close call with potential to cause injury to personnel or damage to property and is used interchangeably with the term "mishap or close call."

A.17 Incident Case Files. All documentation pertaining to a reported incident that include as a minimum, the initial incident notification information, mishap report, and CAP.

A.18 Incident Commander. The individual responsible for all incident management and response activities, including the development of strategies and tactics, and the control of resources. The Incident Commander has overall authority and responsibility for conducting incident operations and can be a NASA employee (internal) or from an external emergency response organization.

A.19 Incident Reporting Information System (IRIS). A NASA mishap data base managed and maintained by the NASA Safety Center which contains initial incident notification information, mishap investigation data, mishap report, and provides tools to track CAPs to completion, submits status and closure data to NASA HQ, and performs mishap trend analysis.

A.20 Interim Response Team (IRT) . An individual or team that arrives at the mishap scene immediately after an incident; secures the scene; documents the scene using photography, video, sketches, and debris mapping; identifies witnesses; collects written witness statements and contact information; preserves evidence; impounds evidence (at the scene and other NASA locations as needed); collects debris; implements the chain-of-custody process for the personal effects of the injured and deceased; notifies the NASA Public Affairs Officer about casualties, damages, and any potential hazards to the public and NASA personnel; advises the supervisor if drug testing should be initiated; and provides all information and evidence to the investigating authority. The team is considered "interim" because it operates as a short-term response team and concludes its mishap-response activities when the official NASA-appointed investigating authority arrives to the scene and takes control. At HQ the IRT comprises the HQ Safety Officer, safety specialist, and industrial hygienist. The Health Unit medical staff may be included, as necessary. The IRT serves as the initial Mishap Investigator and continues this role until a determination can be made as to the need for, and selection of, an Investigating Authority.

A.21 Investigating Authority. The individual mishap investigator, mishap investigation team, or mishap investigation board authorized to conduct an investigation for NASA. This includes the mishap investigation board chairperson, voting members, and ex officio representative, but not the advisors and consultants.

A.22 Investigation Report. A document that is technically accurate and easily understandable in describing the events that led to a mishap. It includes an executive summary describing the events, traceability between facts (i.e., what , when, where), findings (i.e., proximate cause(s), root cause(s), contributing factor(s), failed barrier(s), observation(s), and other evidence upon which the findings were based), graphical or a similar method to representing the mishap, description of analysis techniques, investigation timeline, OSHA 301 Form: Injury and Illness Incident Report or equivalent form if the mishap is an OSHA recordable mishap, conclusions, recommendations, minority report if there is one, and signatures of the Investigation Authority, advisors, and ex officio demonstrating their approval of the mishap report.

A.23 IRIS Administrator. An employee , normally the HQ Safety Officer, in the HQ Safety Office who has been trained, given an IRIS account, and given the overall responsibility to ensure all mishap data for HQ are entered and updated.

A.24 Lessons Learned. The written description of knowledge or understanding that is gained by experience, whether positive (such as a successful test of mission), or negative (such as a mission failure).

A.25 Lost Workday Case (Lost-time Injury/Illness). A nonfatal traumatic injury that causes any loss of time from work beyond the day or shift it occurred; or a non- traumatic illness that causes disability at any time.

A.26 Lost Workdays. The number of days (consecutive or not) after, but not including, the day of injury or illness during which the employee would have worked but could not do so; i.e., could not perform all or any part of his normal assignment during all or any part of the workday or shift because of the occupational injury or illness. This includes days away, restricted duty, or transfer to another job. The total number includes weekends and holidays occurring during the lost workday period.

A.27 Medical Treatment. The management and care of a patient to combat disease or disorder. Includes treatment administered by a physician or by a registered professional under the standing orders of a physician. Medical treatment does not include visits to a physician for observation or counseling, diagnostic procedures such as X-rays and blood test including administration of prescription medications used solely for diagnostic purposes or first aid treatment even though provided by a physician or registered professional personnel.

A.28 Mishap Investigation Board (MIB). A NASA-sponsored board that is appointed for a Type A mishap, Type B mishap, or high-visibility mishap, or high-visibility close call; requires concurrence from the Chief/OSMA and the Chief Engineer on membership; consists of an odd number of Federal employees (including the chairperson) where the majority of the members are independent from the mishap operation; includes a safety officer and human factors mishap investigator. For all Type A mishaps involving injury, illness, or fatality, it also includes an occupational health physician as a member.

A.29 Mishap Investigation Team (MIT). A NASA-sponsored team that is appointed by the ED or designee for Type C mishap, Type D mishap, or close call; consists of an odd number of Federal employees (including the chairperson) with the majority of members independent of the mishap operation; and includes a safety officer and human factors mishap investigator as members.

A.30 Mishap Investigator (MI). A Federal employee who has expertise and experience in mishap or close call investigations; has knowledge of human error analysis in mishaps; serves as the sole investigator for a Type C mishap, Type D mishap, or close call; and is tasked to investigate the mishap or close call and generate the mishap report per this HQPR and the NPR 8621.1, "NASA Procedural Requirements for Mishap and Close Call Reporting, Investigating, and Recordkeeping."

A.31 Mishap Preparedness and Contingency Plans. Pre- approved documents outlining timely organizational activities and responsibilities that are to be accomplished in response to emergency, catastrophic, or potential (but not likely) events encompassing injuries, loss of life, property damage, or mission failure.

A.32 Mission Failure. A mishap of whatever intrinsic severity that, in the judgment of the Mission Directorate Associate Administrator (MDAA), program/project manager, or the Chief/ OSMA, prevents the achievement of primary NASA mission objectives as described in the Mission Operations Report or equivalent document.

A.33 NASA Mishap. An unplanned event that results in at least one of the following: (a) injuryto non-NASA personnel, caused by a NASA operation; (b) damage to public or private property caused by NASA operations or NASA- funded development or research projects; (c)occupational injury or illness to NASA personnel; (d) NASA mission failure before scheduled completion of the planned primary mission; or (e) destruction or damage to NASA property. The term "mishap" is often used interchangeably with the term "incident."

A.34 NASA Non-mishap. Refer to NPR 8621.1, "NASA Procedural Requirements for Mishap and Close Call Reporting, Investigating and Recordkeeping" Chapter 1.2 "Description of NASA Mishaps and Close Calls" for a full description of what is not considered as a NASA mishap (1.2.2).

A.35 Observation. A factor, event, or circumstance identified during the investigation that did not contribute to the mishap or close call, but, if left uncorrected, has the potential to cause a mishap or increase the severity of a mishap; or a factor, event, or circumstance that is positive and needs to be noted.

A.36 Organizational Factor. Any operational or management structural entity that exerts control over the system at any stage in its life cycle, including, but not limited to, the system's concept development, design, fabrication, test, maintenance, operation, and disposal; i.e., resource management, policy, or management decisions.

A.37 Quick Incident Report. The electronic entry of the initial incident notification information into the IRIS database and can be entered without requiring an IRIS password and can be accessed at http://nasa.ex3host.com/IRIS/.

A.38 Permanent Total Disability. Any nonfatal injury or occupational illness that, in the opinion of a competent medical authority, permanently or totally incapacitates a person to the extent that he/she cannot follow any gainful occupation and results in a medical discharge or civilian equivalent.

A.39 Permanent Partial Disability. Any injury or occupational illness that does not result in a fatality or permanent total disability, but, in the opinion of a competent medical authority, results in permanent impairment through loss of use of any part of the body, with the following exceptions: loss of teeth, loss of fingernails or toenails, loss of tip of fingers or tip of toe without bone involvement, inguinal hernia (if it is repaired), disfigurements, or sprains or strains that do not cause permanent limitation of motion.

A.40 Proximate Cause. The event(s) that occurred, including any condition(s) that existed immediately before the undesired outcome, directly resulted in its occurrence and, if eliminated or modified, would have prevented the undesired outcome. This is also known as direct cause(s).

A.41 Responsible Organization. The organization that is directly responsible for the activity or operation/program where the mishap/incident occurred. This also refers to the lowest level of the organization where corrective actions are implemented.

A.42 Root Cause. One of multiple factors (events, conditions, that are organizational factors) that contributed to or created the proximate cause and subsequent undesired outcome and, if eliminated or modified, would have prevented the undesired outcome.

A.43 SATERN. System for Administration, Training, and Educational Resources for NASA https://satern.nasa.gov/

A.44 Serious Workplace Hazard. A condition, practice, method, operation, or process that has a substantial probability that death or serious physical harm could result and the employer did not know of its existence or did not exercise reasonable diligence to control the presence of the hazard.

A.45 Type A Mishap. A mishap resulting in one or more of the following: (1) an occupational injury or illness resulting in a fatality, a permanent total disability, or hospitalization for inpatient care of three or more people within 30 workdays of the mishap; (2) a total direct cost of mission failure and property damage of $2 million or more; (3) a crewed aircraft hull loss; or (4) unexpected aircraft departure from controlled flight, excepting high performance jet/test aircraft.

A.46 Type B Mishap. A mishap that caused an occupational injury or illness that resulted in a permanent partial disability, the hospitalization for inpatient care of one or two people within 30 workdays of the mishap, or a total direct cost of mission failure and property damage of at least $500,000, but less than $2 million.

A.47 Type C Mishap. A mishap resulting in a nonfatal occupational injury or illness that caused any days away from work, restricted duty, or transfer to another job beyond the day of the shift on which it occurred, or total direct cost of mission failure and property damage of at least $50,000, but less than $500,000.

A.48 Type D Mishap. A mishap that caused any nonfatal OSHA recordable occupational injury and/or illness that does not meet the definition of a Type C Mishap or a total direct cost of mission failure and property damage at least $1,000, but less than $50,000.

A.49 Witness. A person who has information, evidence, or proof about a mishap and provides his/her knowledge of the facts to the investigating authority.

A.50 Witness Statement. A verbal or written statement from an individual that describes his/her account of what he/she witnessed that includes a description of the sequence of events, facts, conditions, and/or causes of the mishap.


[<< back <<]