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HQPR 8621.1
Effective Date: November 08, 2011
Expiration Date: June 08, 2019
Responsible Office: LM
Mishap Reporting, Investigating, and Recordkeeping Program and Plan
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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 K: Example of HQ Type C, Type D, and Low- Visibility Incident/Mishap Report

TO: ABC/Name


Subject: Investigation of Mishap (Title), IRIS No.

The investigation of the (Title) mishap has been completed, and the results are as follows:

Incident Description: (What happened, when it happened, who reported it, what actions were taken and the timeline).

Finding: (What the investigation revealed) Discussion:

Proximate Cause(s), Root Cause(s), and Contributing Factors:


Lessons Learned (if any):


MIT Chairperson's or MI's Name

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