HQpr 8621.1

NASA Headquarters' Directives
HQpr 8621.1 Effective Date: November 08, 2011 Expiration Date: June 08, 2019 Responsible Office: LA	Mishap Reporting, Investigating, and Recordkeeping Program and Plan

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APPENDIX B: HQ Mishap Response Checklist

This checklists covers:

1) All mishaps and close calls that occur at HQ.

2) All off-site locations performing HQ (e.g., facility) work that is not managed by a program or any Mission Directorate Associate Administrator.

3) If HQ manages an aircraft program, this is also for all aircraft mishaps and close calls involving those aircraft.

*HQPR 8621.1 serves as the HQ Mishap Preparedness and Contingency Plan, and helps with this process and defines HQ personnel’s roles and responsibilities.

** For a Type A mishap, Type B mishap, high visibility mishap or high visibility close call, the Executive Director, Office of HQ Operations is the Appointing Official for the Mishap Investigating Authority. In this capacity he has a number of tasks. (For a Type C mishap, Type D mishap and close call, the Executive Director may designate an appointing official. At HQ this person is the Director, Facilities and Administrative Services Division (Refer to HQPR 8621. Chapter 2).

Steps for the Appointing Official

NPR 8621.1/HQPR 8621.1

Requirement

Paragraph Number

Resource

Action

Completed

(yes or no)

Verify that an Interim Response Team (IRT) is at the accident scene.

Send the IRT to collect written statements, photos, etc., even if there is a collateral investigation evaluating the potential for sabotage. Both investigations (safety and Inspector General) are conducted simultaneously and are looking for different things.

Recommended

Pre-identified and trained team listed in the plan

Hold a meeting to evaluate the accident response:

Possible questions:

¨ How are the emergency response and/or rescue activities progressing?

¨ Who is in charge of the mishap scene (e.g., First Responders or NASA)?

¨ Are immediate needs being met with respect to:

§ Identifying and safing hazardous materials,

§ Providing Personnel Protective Equipment (PPE) and investigation resources (go kits) on the scene,

§ Securing the scene,

§ Impounding evidence, and

§ Initiating post-mishap drug testing.

¨ Does any information need to be released to the HQ employees or the public to ensure the safety of other personnel (e.g., from toxic gases, fires, etc.)?

* Once a Mishap Investigation Board or Team is appointed, they will coordinate the release of information with public affairs. Until that time, the Executive Director coordinates the release.

Recommended

Go-kit list,

impound list, and impound process.

Can be found on the NASA Mishap Investigation Website:

https://secureworkgroups .

grc.nasa.gov/mi

Determine the mishap classification level (or assign a designee to determine the classification level) for all mishaps and close calls.

NPR 8621.1 1.4.7 d

HQPR 8621.1

5.1

Classifications in NPR 8621.1 Figure 1

HQPR 8621.1

Appendix F

For Type A mishaps, Type B mishaps, high visibility mishaps and high visibility close calls - Verify that HQ OSMA has been contacted within 1 hour of the mishap. (This triggers a series of notifications to Agency Officials-in-Charge, including General Counsel, Public Affairs, and more.)

NPR 8621.1 1.5.3

HQPR 8621.1

3.3.3

Obtain concurrence on this classification level from the Chief/OSMA for Type A mishaps, Type B mishaps, high- visibility mishaps, and high-visibility close calls.

NPR 8621.1 1.4.7 d

HQPR 8621.1

5.1.4

For an aircraft mishap that meets NTSB reporting requirement - Verify NTSB has been contacted by HQ Chief of Aircraft Operations. (The NTSB notification is required by law for certain mishaps.)

NPR 8621.1 1.6.6

NPR 8621.1 Figure 3 lists NTSB reportable mishaps

Within 8 hours of the mishap, verify that OSHA has been contacted when HQ has had a work-related mishap involving death of a Federal employee, or the hospitalization for inpatient care of three or more employees (provided that at least one is a Federal employee). (The OSHA notification is required by law.)

NPR 8621.1 1.5.4

HQPR 8621.1

3.4.1

HQPR 8621.1, Appendix D

Determine the level of the investigation based on the severity of the mishap. (ED may elevate the investigation level as desired.)

NPR 8621.1 1.4.7 d

HQPR 8621.1

5.1.2

Level of investigation Figure 1

HQPR 8621.1

Appendix F.1 and F.2

Within 48 hours of accident, appoint the Investigating Authority.

      Identify candidates to serve on the Mishap Investigation Board (MIB) -5 members plus Ex Officio for Type A mishap, Type B mishap, high visibility mishap or high visibility close call; or Mishap or Investigation Team (MIT) - 3 members plus Ex Officio for Type B or lower level accidents.

     Candidate List

¨ All federal employees

¨ Odd number of voting members

¨ Majority independent from program/project or activity with mishap

¨ Not from the direct chain of authority responsible for day-to-day or line management oversight of the facility, area, or activity involved in the mishap or have a vested interest in the outcome of the investigation

¨ One trained safety person

¨ One trained human factors professional (if a MIB or MIT)

¨ If mishap involves serious injury, illness, or fatality – one medical doctor

¨ If mishap involves an aircraft –one member knowledgeable in aircraft operations, a member knowledgeable in aircraft maintenance, and a member knowledgeable in aviation safety (one person can serve multiple functions)

¨ Trained Ex Officio (Not a voting member)

* Select candidates that can dedicate their time. Trained candidates that can dedicate their time will result in faster investigations. Consider discipline experts as advisors to support trained candidates.

NPR 8621.1 4.2.7

HQPR 8621.1, 5.2 and 5.3

See Mishap Website for a List of NASA’s employees trained in mishap investigation

Obtain concurrence of candidates for Investigating Authority from Chief, OSMA, and Chief Engineer (and when accident involves injury/fatality, Chief Health and Medical Officer).

NPR 8621.1 4.2.5, 1.4.7g, 1.4.7 n,

NPR 8521.1 Figure 5

HQPR 8621.1

5.3.3

Send candidates to Faith Chandler, OSMA Mishap Mgr. who will put together summary for endorsing officials.

Determine the length of the investigation (not more than 75 workdays). Can be less than 75 work days (your choice). Document this in the appointment letter.

NPR 8621.1 6.1.13

HQPR 8621.1

5.3.5 and 5.4.4

Template of appointment letter on mishap website.

HQPR 8621.1

Appendix G

Personally report, by telephone or e-mail, to the Administrator within 24 hours of learning the instance of any NASA Type A mishap, or NASA Type B mishap, and personally report (or Deputy to report), by telephone or e-mail, to the Associate Administrator within 24 hours of learning the instance of any NASA Type C mishap that involves a lost-time injury or illness).

NPR 8621.1 1.4.7 h

HQPR 8621.1

3.3.1 and 3.3.2

HQPR 8621.1

Appendix C

Request a 30-day status (or more frequent status) from the Investigating Authority.

The investigating authority is required per NPR 8621.1 to provide a status at least every 30-days. This status is to be “facts only” (no privileged, privacy act, international traffic arms regulation (ITAR), export administration regulations (EAR), or pre- decisional information). The status is to be reviewed and approved by their legal advisor and public affairs advisor.

May release the status to everyone at HQ (including contractors) if it is marked “Authorized for Public Release.”

NPR 8621.1 1.8.4, 6.5.9

30-Day Status Template on Mishap Website

If the Investigating Authority identifies a hazard and provides recommendations, request that they complete a NASA Mishap Warning-Action-Response form. This form is circulated throughout the Agency via email, NASA Safety Advisory System, IRIS, and 2 websites.

Recommended

Mishap Warning- Action- Response Template on Mishap Website

Direct the investigating authority (MIB/MIT) to complete their investigation on time. If they are delayed, the appointing official, needs to talk to the chair and request their completed product. (NPR 8621.1 only gives the appointing official the ability to direct/require actions of the investigating authority. OSMA cannot require them to finish more quickly.)

NPR 8621.1 1.4.13

HQPR 8621.1

5.4.5

Attend the Out Brief for Type A mishaps, Type B mishaps, and high visibility mishaps and close calls.

*Once the Investigating Authority has completed their investigation they should provide an out brief to present their findings and recommendations. Invite all endorsing officials to this meeting.

After the briefing is complete, and if the briefing does not contain NASA Sensitive But Unclassified Information, it may be shared with others at HQ.

Immediately, begin implementing the recommendations that are approved.

1.4.12g for OSMA,

HQPR 8621.1

5.4.9

Place the mishap report in IRIS. (This can be completed by the HQ Safety Office person designated in your Mishap Preparedness and Contingency Plan).

NPR 8621.1 1.8.4

HQPR 8621.1

6.1

Send the Report to the endorsing officials requesting an endorsement. The endorsing officials are the Chief, OSMA, and Chief Engineer (and when accident involves injury/fatality, Chief Health and Medical Officer).

NPR 8621.1 6.3.1, 6.3.2

HQPR 8621.1

5.4.6

Generate an endorsement (ED is an endorsing official for Type A mishaps, Type B mishaps, and high visibility mishaps and close calls).

NPR 8621.1 1.4.7q

HQPR 8621.1

5.4.10

When all endorsements are received, approve report and request the responsible group to document the Corrective Action Plan (CAP). (The plan will include those recommendations that ED approved and others that other endorsing officials have added or expanded.)

NPR 8621.1 7.1 and 7.2

HQPR 8621.1

5.4.10

Track the corrective actions to closure, and document this in IRIS. (This can be completed by the HQ Safety Office person designated in the Mishap Preparedness and Contingency Plan).

NPR 8621.1 7.4, 7.5.1- 7.5.3

HQPR 8621.1

5.4.

Request that HQ Public Affairs, Office of General Counsel, Office of External Relations, and others as appropriate authorize the report for public release.

NPR 8621.1

6.4

HQPR 8621.1

5.4.12

23. Distribute the mishap report to the appropriate NASA programs and organizations including, but not limited to, the responsible organization and/or program, the HQ Safety Office, the CHMO (when an injury or fatality has occurred), and AMD (when the mishap involved an aircraft).

NPR 8621.1 6.5.2

HQPR 8621.1

5.9

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Steps for the Appointing Official	NPR 8621.1/HQPR 8621.1 Requirement Paragraph Number	Resource	Action Completed (yes or no)
Verify that an Interim Response Team (IRT) is at the accident scene. Send the IRT to collect written statements, photos, etc., even if there is a collateral investigation evaluating the potential for sabotage. Both investigations (safety and Inspector General) are conducted simultaneously and are looking for different things.	Recommended	Pre-identified and trained team listed in the plan
Hold a meeting to evaluate the accident response: Possible questions: ¨ How are the emergency response and/or rescue activities progressing? ¨ Who is in charge of the mishap scene (e.g., First Responders or NASA)? ¨ Are immediate needs being met with respect to: § Identifying and safing hazardous materials, § Providing Personnel Protective Equipment (PPE) and investigation resources (go kits) on the scene, § Securing the scene, § Impounding evidence, and § Initiating post-mishap drug testing. ¨ Does any information need to be released to the HQ employees or the public to ensure the safety of other personnel (e.g., from toxic gases, fires, etc.)? * Once a Mishap Investigation Board or Team is appointed, they will coordinate the release of information with public affairs. Until that time, the Executive Director coordinates the release.	Recommended	Go-kit list, impound list, and impound process. Can be found on the NASA Mishap Investigation Website: https://secureworkgroups . grc.nasa.gov/mi
Determine the mishap classification level (or assign a designee to determine the classification level) for all mishaps and close calls.	NPR 8621.1 1.4.7 d HQPR 8621.1 5.1	Classifications in NPR 8621.1 Figure 1 HQPR 8621.1 Appendix F
For Type A mishaps, Type B mishaps, high visibility mishaps and high visibility close calls - Verify that HQ OSMA has been contacted within 1 hour of the mishap. (This triggers a series of notifications to Agency Officials-in-Charge, including General Counsel, Public Affairs, and more.)	NPR 8621.1 1.5.3 HQPR 8621.1 3.3.3
Obtain concurrence on this classification level from the Chief/OSMA for Type A mishaps, Type B mishaps, high- visibility mishaps, and high-visibility close calls.	NPR 8621.1 1.4.7 d HQPR 8621.1 5.1.4
For an aircraft mishap that meets NTSB reporting requirement - Verify NTSB has been contacted by HQ Chief of Aircraft Operations. (The NTSB notification is required by law for certain mishaps.)	NPR 8621.1 1.6.6	NPR 8621.1 Figure 3 lists NTSB reportable mishaps
Within 8 hours of the mishap, verify that OSHA has been contacted when HQ has had a work-related mishap involving death of a Federal employee, or the hospitalization for inpatient care of three or more employees (provided that at least one is a Federal employee). (The OSHA notification is required by law.)	NPR 8621.1 1.5.4 HQPR 8621.1 3.4.1	HQPR 8621.1, Appendix D
Determine the level of the investigation based on the severity of the mishap. (ED may elevate the investigation level as desired.)	NPR 8621.1 1.4.7 d HQPR 8621.1 5.1.2	Level of investigation Figure 1 HQPR 8621.1 Appendix F.1 and F.2
Within 48 hours of accident, appoint the Investigating Authority. Identify candidates to serve on the Mishap Investigation Board (MIB) -5 members plus Ex Officio for Type A mishap, Type B mishap, high visibility mishap or high visibility close call; or Mishap or Investigation Team (MIT) - 3 members plus Ex Officio for Type B or lower level accidents. Candidate List ¨ All federal employees ¨ Odd number of voting members ¨ Majority independent from program/project or activity with mishap ¨ Not from the direct chain of authority responsible for day-to-day or line management oversight of the facility, area, or activity involved in the mishap or have a vested interest in the outcome of the investigation ¨ One trained safety person ¨ One trained human factors professional (if a MIB or MIT) ¨ If mishap involves serious injury, illness, or fatality – one medical doctor ¨ If mishap involves an aircraft –one member knowledgeable in aircraft operations, a member knowledgeable in aircraft maintenance, and a member knowledgeable in aviation safety (one person can serve multiple functions) ¨ Trained Ex Officio (Not a voting member) * Select candidates that can dedicate their time. Trained candidates that can dedicate their time will result in faster investigations. Consider discipline experts as advisors to support trained candidates.	NPR 8621.1 4.2.7 HQPR 8621.1, 5.2 and 5.3	See Mishap Website for a List of NASA’s employees trained in mishap investigation
Obtain concurrence of candidates for Investigating Authority from Chief, OSMA, and Chief Engineer (and when accident involves injury/fatality, Chief Health and Medical Officer).	NPR 8621.1 4.2.5, 1.4.7g, 1.4.7 n, NPR 8521.1 Figure 5 HQPR 8621.1 5.3.3	Send candidates to Faith Chandler, OSMA Mishap Mgr. who will put together summary for endorsing officials.
Determine the length of the investigation (not more than 75 workdays). Can be less than 75 work days (your choice). Document this in the appointment letter.	NPR 8621.1 6.1.13 HQPR 8621.1 5.3.5 and 5.4.4	Template of appointment letter on mishap website. HQPR 8621.1 Appendix G
Personally report, by telephone or e-mail, to the Administrator within 24 hours of learning the instance of any NASA Type A mishap, or NASA Type B mishap, and personally report (or Deputy to report), by telephone or e-mail, to the Associate Administrator within 24 hours of learning the instance of any NASA Type C mishap that involves a lost-time injury or illness).	NPR 8621.1 1.4.7 h HQPR 8621.1 3.3.1 and 3.3.2	HQPR 8621.1 Appendix C
Request a 30-day status (or more frequent status) from the Investigating Authority. The investigating authority is required per NPR 8621.1 to provide a status at least every 30-days. This status is to be “facts only” (no privileged, privacy act, international traffic arms regulation (ITAR), export administration regulations (EAR), or pre- decisional information). The status is to be reviewed and approved by their legal advisor and public affairs advisor. May release the status to everyone at HQ (including contractors) if it is marked “Authorized for Public Release.”	NPR 8621.1 1.8.4, 6.5.9	30-Day Status Template on Mishap Website
If the Investigating Authority identifies a hazard and provides recommendations, request that they complete a NASA Mishap Warning-Action-Response form. This form is circulated throughout the Agency via email, NASA Safety Advisory System, IRIS, and 2 websites.	Recommended	Mishap Warning- Action- Response Template on Mishap Website
Direct the investigating authority (MIB/MIT) to complete their investigation on time. If they are delayed, the appointing official, needs to talk to the chair and request their completed product. (NPR 8621.1 only gives the appointing official the ability to direct/require actions of the investigating authority. OSMA cannot require them to finish more quickly.)	NPR 8621.1 1.4.13 HQPR 8621.1 5.4.5
Attend the Out Brief for Type A mishaps, Type B mishaps, and high visibility mishaps and close calls. *Once the Investigating Authority has completed their investigation they should provide an out brief to present their findings and recommendations. Invite all endorsing officials to this meeting. After the briefing is complete, and if the briefing does not contain NASA Sensitive But Unclassified Information, it may be shared with others at HQ. Immediately, begin implementing the recommendations that are approved.	1.4.12g for OSMA, HQPR 8621.1 5.4.9
Place the mishap report in IRIS. (This can be completed by the HQ Safety Office person designated in your Mishap Preparedness and Contingency Plan).	NPR 8621.1 1.8.4 HQPR 8621.1 6.1
Send the Report to the endorsing officials requesting an endorsement. The endorsing officials are the Chief, OSMA, and Chief Engineer (and when accident involves injury/fatality, Chief Health and Medical Officer).	NPR 8621.1 6.3.1, 6.3.2 HQPR 8621.1 5.4.6
Generate an endorsement (ED is an endorsing official for Type A mishaps, Type B mishaps, and high visibility mishaps and close calls).	NPR 8621.1 1.4.7q HQPR 8621.1 5.4.10
When all endorsements are received, approve report and request the responsible group to document the Corrective Action Plan (CAP). (The plan will include those recommendations that ED approved and others that other endorsing officials have added or expanded.)	NPR 8621.1 7.1 and 7.2 HQPR 8621.1 5.4.10
Track the corrective actions to closure, and document this in IRIS. (This can be completed by the HQ Safety Office person designated in the Mishap Preparedness and Contingency Plan).	NPR 8621.1 7.4, 7.5.1- 7.5.3 HQPR 8621.1 5.4.
Request that HQ Public Affairs, Office of General Counsel, Office of External Relations, and others as appropriate authorize the report for public release.	NPR 8621.1 6.4 HQPR 8621.1 5.4.12
23. Distribute the mishap report to the appropriate NASA programs and organizations including, but not limited to, the responsible organization and/or program, the HQ Safety Office, the CHMO (when an injury or fatality has occurred), and AMD (when the mishap involved an aircraft).	NPR 8621.1 6.5.2 HQPR 8621.1 5.9