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
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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

CHAPTER 5. Mishap/Incident Classification and Investigation Process

5.1 Determining Classification Level and Type of Investigation

5.1.1 The Executive Director, HQ Operations has the overall responsibility for determining the mishap classification and with the support of the HQ Safety Office will determine the incident classification. The management of the organization where the mishap occurred may be consulted where appropriate.

5.1.2 The severity of personnel injury and the direct cost of the incident shall be considered when determining the mishap classification and the level of investigation necessary. The mishap classification and type of investigation shall be based on Mishap Type and Direct Costs definitions provided in Appendix A: Terms and Definitions, and Appendix F: Mishap Classification Levels and Appendix G: Mishap Classification and Investigation Type.

5.1.3 If the mishap/incident is believed to be a high- visibility incident, the Executive Director, HQ Operations can elevate the incident classification to one deemed appropriate.

5.1.4 The Executive Director, HQ Operations with support from the HQ Safety Officer shall contact the Chief, OSMA for concurrence when determining the classification of Type A, Type B, and high-visibility incidents.

5.1.5 The incident classification or level of investigation can be elevated by the NASA Administrator, Associate Administrator, Chief, OSMA, or Chief, Health and Medical Officer (CHMO).

5.1.6 For Type C mishaps that do not involve a civil servant lost-time injury or illness, Type D and low- visibility incidents, the results of the initial investigation conducted by the HQ Safety Office may be used to determine if a more extensive investigation is necessary.

5.1.7 For Type C, Type D, and low-visibility incidents that do not involve NASA employees or equipment, the initial investigation can be conducted by the organization or contractor directly responsible for the area or activity where the incident occurred. This does not prevent the HQ Safety Office from conducting it's investigation.

5.2 Investigation Appointing Official

5.2.1 For Type A, Type B and high-visibility incidents, the Executive Director, shall serve as the appointing official unless elevated by the NASA Administrator or Chief, OSMA.

5.2.2 For onsite Type C, Type D mishaps, and low visibility incidents, the Director, FASD or designee will serve as the Appointing Official, unless elevated by the Executive Director.

5.2.3 The Appointing Official's responsibilities shall include the responsibilities of the Endorsing and Approving official as specified in NPR 8621.1B.

5.3 Appointing the Investigating Authority

5.3.1 For Type A, Type B, or Type C that involves a civil servant lost-time injury or illness, and any high- visibility incidents the Appointing Official shall appoint the Investigating Authority [MIB, MIT, or Mishap Investigator (MI)] within 48 hours of the mishap.

5.3.2 The incident classification or level of visibility shall be used to determine the Investigating Authority (MIB, MIT, or MI) composition, membership, number of voting members and level of independence necessary.

5.3.3 OSMA must concur on the board membership for Type A, Type B, and high-visibility incidents. See NPR 8621.1, section 4.2.6, for additional requirements on MIBs.

5.3.4 For Type C that do not involve civil servant lost time injury or illness, Type D, and low visibility incidents, the Appointing Official shall appoint the Investigation Authority (MIB, MIT, or MI) within 72 hours of the mishap.

5.3.5 The Appointing Official shall prepare a letter of appointment for the Investigating Authority with the support of the HQ Safety Office. All investigating authorities shall have at least one person trained in mishap investigation. The MIB or MIT shall consist of one or more people who have expertise or training in the area of investigation and an advisor from the HQ Safety Office to serve as the Ex-Officio (Refer to Appendix A: Terms and Definitions), unless the appointing official designates someone else.

5.3.6 For Type A, Type B and high-visibility incidents, the Investigating Authority composition and membership shall be federal employees independent of the organization that experienced the incident, not from the direct chain of authority for day to-day or line management oversight of the facility or operations/activity involved in the incident, and not have a vested interest in the outcome of the investigation. See NPR 8621.1, "NASA Procedural Requirements for Mishap and Close Call Reporting, Investigating, and Recordkeeping" Chapter 4, "Select the Investigating Authority and Support."

5.3.7 Contractors identified to have sufficient experience and technical expertise in the area or activity performed where the incident occurred can be identified by the Appointing Official to support the Investigating Authority in the role of a consultant.

5.3.8 For Type A, Type B and high-visibility incidents, the Appointing Official shall issue an Investigation Authority appointment letter to document the membership of the Investigating Authority; its charter; due date of when the incident investigation is expected to be completed, and date of when the mishap report is expected to be approved. (Refer to Appendix H: Example of Investigating Authority Appointment Letter.)

5.3.9 Employees selected to serve in the role of advisors shall be identified in the Investigation Authority appointment letter. Advisors may include a legal advisor, public affairs advisor, import/export control advisor, and external relations advisor, as necessary.

5.3.10 For Type C, Type D, and low-visibility incidents with the potential for Type C or less, the Investigation Authority appointment letter can be made by an e-mail addressing the items in 5.3.8.

5.3.11 If a HQ Contractor Investigating Authority is required to investigate a Contractor incident, its membership, charter and due date shall be determined by the Contractor per the requirements of their contract; however, HQ can convene a HQ Investigating Authority to also investigate a Contractor incident, if desired.

5.4 Conducting an Incident Investigation

5.4.1 After the immediate emergency response actions have been accomplished and the Investigating Authority appointed, the formal investigation shall begin. The primary purpose of the investigation is to determine proximate and root cause(s) that led to the incident and to develop recommendations for corrective actions to prevent recurrences.

5.4.2 Investigations shall be conducted in accordance with NPR 8621.1 and other requirements defined in the appointment letter.

5.4.3 The Investigating Authority shall prepare its report in accordance with the requirements of NPR 8621.1, including findings and recommendations.

5.4.4 The Investigating Authority shall submit the mishap investigation report to the Appointing Official, with a copy to the responsible organization, for review and comment before finalization.

5.4.5 Unless otherwise specified in writing by the Appointing Official, the mishap report shall be submitted 60 calendar days from the date of the appointment letter.

5.4.6 The Investigating Authority shall make every attempt to meet the mishap investigation timeline specified in NPR 8621.1 and the appointment letter. If the investigation is expected to exceed the timelines, the Investigating Authority shall notify the Appointing Official, in writing.

5.4.7 The Appointing Official can identify reviewers and endorsing officials to be part of the review. The Appointing Official shall determine the endorsing officials for the mishap report based on the type of incident in accordance with the matrix of responsibilities outlined in Appendix G: Mishap Classification and Investigation Type.

5.4.8 If the Appointing Official, reviewers or endorsing officials wish to provide comments on the mishap report they shall be consolidated by the Appointing Official and sent back to the Investigating Authority within 15 calendar days.

5.4.9 The Investigating Authority may incorporate the comments (or not, at their discretion) into the mishap report and submits the report to the Appointing Official.

5.4.10 The Investigating Authority shall provide a briefing of the investigation observations, findings and recommendations to the Appointing Official, as necessary.

5.4.11 The Appointing Official shall complete a review of the mishap report, endorse and approve the report within 15 calendar days of it's receipt from the Investigating Authority. The approved mishap report shall also include the approval by the endorsing officials.

5.4.12 If the mishap report is rejected, a new Investigating Authority shall be assigned.

5.4.13 The approved mishap report for Type A, Type B and high-visibility incidents shall be sent to the appropriate level HQ legal official, import/export control official, public affairs official, and any other HQ official(s) as appropriate for review of compliance with NASA policies and authorization for public release. This should typically be completed within 120 workdays of the mishap.

5.4.14 Within 115-120 workdays of the mishap, the CAP and Lessons Learned, if any, should be developed as assigned by the mishap report.

5.4.15 A typical investigation timeline for Type C, Type D and low-visibility mishaps and incidents generally follow the same sequence of steps provided above, but normally with a shorter timeline, typically 30 calendar days from the incident.

5.4.16 A Mishap/Incident Investigation Form (Refer to Appendix I: Mishap/Incident Investigation Form) or report format (Appendix K: Example of HQ Type C, Type D, and Low- Visibility Incident/Mishap Report) may be used for less complex investigations such as Type C that do not include a lost time, Type D and low visibility incidents, and submitted to the HQ Safety Office.

5.5 Corrective Action Plan (CAP)

5.5.1 The Appointing Official may task the organization directly responsible for the area or activity/operation where the incident occurred to develop and submit a CAP based on the recommendations and conclusions of the mishap report.

5.5.2 A CAP shall be developed for all incidents as directed by the Appointing Official and submitted to the Investigation Appointing Official within 15 calendar days of their receipt of the mishap report.

5.5.3 The CAP shall address the recommendations that are identified in the mishap report including the actions necessary to correct the situation(s) that caused the incident, and prevent the same or similar incidents from recurring. The CAP shall include the following:

a. A description of the corrective actions implemented to eliminate the identified causes of the incident.

b. Identify the organizations, including contractors, that are responsible for performing and ensuring the corrective action has been implemented and are complete.

c. An expected completion date for each action. These dates are provided by the organization assigned the action.

d. A matrix that matches the corrective actions to the root causes or findings of the incident.

e. A review of any process changes that were required based on the corrective actions. 5

.5.4 The Appointing Official shall be responsible for the acceptance or rejection of the CAP, with support for assessing the CAP from the HQ Safety Office.

5.5.5 If the CAP is rejected by the Appointing Official, it shall be returned with comments to the organization that developed the CAP for revision and re-submittal within an established timeframe.

5.5.6 If the CAP is accepted, the Appointing Official shall direct the organization that developed the CAP to implement the corrective actions identified in the CAP. If an organization cannot implement the assigned corrective action, they shall contact the Appointing Official, and/or the HQ Safety Office for assistance.

5.5.7 Typically, the organization(s) assigned responsibilities in the CAP shall perform the following activities:

a. Implement corrective actions as recommended by the CAP and notify the Appointing Official and the HQ Safety Office as each assigned action is completed.

b. Formally document corrective actions that cannot be implemented within 30 days by completing NASA Form1584, "NASA Hazard Abatement Plan" or a similar form that provides (1) the reason the corrective action cannot be corrected within 30 days, (2) a description of the temporary measures taken to control the hazard, (3) a description of the long-term corrective action, and (4) the expected completion date.

c. Provide monthly status of each open corrective action. Send a status update to the HQ Safety Office by the 15th of each month.

5.5.8 All CAP corrective actions shall be considered open until the Appointing Official and HQ Safety Office have received notification or evidence of their closure.

5.5.9 The Appointing Official, with assistance from the HQ Safety Office, shall determine if the evidence provided of the corrective action completion is sufficient to close the open action.

5.5.10 The CAP may be distributed to other appropriate organizations, NASA HQ, other NASA Centers, and other Federal agencies, if determined necessary by the Appointing Official.

5.5.11 The corrective actions identified in the CAP shall be entered into IRIS by the HQ Safety Office IRIS administrator/representative and updated as each corrective action is completed.

5.5.12 Prior to the closure of the incident case file, the HQ Safety Office shall ensure all corrective actions identified in the CAP have been implemented and notify the Appointing Official of any corrective actions that were reported closed, but discovered not implemented or not effective.

5.5.13 The HQ Safety Office and the organization directly responsible for the area or operation where the incident occurred shall periodically monitor the effectiveness of the corrective actions to ensure they are effective.

5.6 Lessons Learned

5.6.1 The Appointing Official shall designate an individual from the organization where the incident occurred or the Investigating Authority to develop Lessons Learned that are identified as significant, valid, and applicable to be provided within 10 work days.

5.6.2 Lessons learned shall be developed based on information discovered during the investigation and identified in the investigation report. This information is normally gathered from the findings and recommendations listed in the investigation report.

5.6.3 Lessons learned shall provide information as to what actions or precautions are necessary to prevent similar incidents from occurring in the future.

5.6.4 The Appointing Official shall approve the Lessons Learned to ensure they provide the necessary information to prevent similar incidents from occurring in the future.

5.6.5 Lessons Learned that result from an incident investigation shall be entered into IRIS before the incident case file report can be closed.

a. The IRIS Lessons Learned module is linked to the NASA Learned Information System.

b. There may be times when the investigation reveals no lessons learned as with some IRIS entries for first aid.

5.7 Mishap Warning-Action-Response

5.7.1 The Mishap Warning-Action-Response is a method of sharing information discovered during the investigation with other NASA Centers prior to closure of the investigation report.

5.7.2 The Investigating Authority shall initiate a Mishap Warning-Action-Response if it feels information discovered during the investigation is applicable to similar facility/operations at other NASA Centers. The HQ Safety Office can assist the Investigating Authority in this decision.

5.7.3 The HQ Safety Office shall distribute the Mishap Warning-Action-Response reports received from the NASA Safety Center (NSC) to all HQ Organizations as appropriate.

5.8 Process to Close an Incident Case File

5.8.1 When all corrective actions listed in the CAP have been completed and closed, the Appointing Official shall sign the closeout letter/statement and forward the package to the HQ Safety Office to be added to the Case File.

5.8.2 The final closure statement shall include all of the following:

a. An investigation completion statement.

b. The CAP that includes the final status of the corrective actions, including any final deviations from the plan (e.g., completion date changes, performing organization changes). It is not necessary to create a new report to fulfill this requirement. Only the final status needs to be developed for this deliverable.

5.8.3 The HQ Safety Office shall ensure all corrective actions identified in the CAP have been implemented and the CAP is complete.

5.8.4 Upon completion of the tasks identified in the preceding paragraphs, the HQ Safety Office shall ensure that the mishap report is distributed to other appropriate organizations, OSMA/SARD, other NASA Centers, and other Federal agencies as determined necessary. At this point, the Investigation Appointing Official has met the obligations for this incident and is released from this position.

5.9 Closing the Incident Case File in IRIS

5.9.1 The HQ IRIS Administrator (HQ Safety Officer) shall close the incident case file in IRIS after all the following items are shown as completed in IRIS:

a. Appointment letter or similar from the Appointing Official that establishes the need for an Investigation Authority and includes the members names.

b. The mishap report.

c. Letter or similar method that indicates concurrence from the Appointing Official with the contents in the final investigation report.

d. Lessons Learned, if any, have been entered into IRIS.

e. Endorsements and concurrences with the mishap report.

5.10 Distributing Mishap Report Information

5.10.1 The HQ Safety Office shall ensure mishap reports are distributed to all HQ organizations with assigned responsibility and other HQ organizations as determined necessary by the Appointing Official and the Director, FASD.

5.11 Incidents Involving Criminal Activity, Weather, Aircraft, or Motor Vehicle

5.11.1 If it is suspected that a reported incident resulted from criminal activity, the Office of Inspector General (OIG) and the Office of the Chief Counsel shall be notified. Criminal activity, by definition, is not a mishap.

5.11.2 When an incident is not considered a mishap because the initiating event (proximate case) is natural phenomenon or weather, the HQ Safety Office shall enter the incident and a description of the damage into IRIS.

5.11.3 Incidents related to motor vehicles shall be reported and investigated in accordance with NPR 4200.1, "NASA Equipment Management Procedural Requirements."

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