302. March 26, 2001

TO: Executive Council

> 300/Distribution

FROM: 300/Director, Office of Systems Safety & Mission Assurance

SUBJECT: Mishap Reporting

In order to help bring the Center into full compliance with the Agency's
regulations, the Office of Systems Safety and Mission Assurance has
agreed to coordinate and integrate the Goddard Mishap Reporting and
Investigation process. We are currently developing a Centerwide process
for documenting, investigating, correcting, and preventing Mishaps. A
Mishap is "Any unplanned occurrence or event resulting from any NASA
operation, or NASA equipment anomaly, involving injury or death to
persons. Damage to or loss of property or equipment, or mission failure,
provided that a written agreement or contract between NASA and another
party did not otherwise allocate operational control and corrective
action responsibility." NASA Mishaps are categorized as Type A, B, C,
Mission Failure and Incident. For definitions of the types of Mishaps
refer to NPD 8621.1G, found on the NASA On-Line Directives Information
System (NODIS) at <http://nodis3.gsfc.nasa.gov/library/main_lib.html>.
NASA has a training module in the NASA Site for On-Line Learning
Resources covering Mishap Reporting and Investigation at
[https://solar.msfc.nasa.gov](https://solar.msfc.nasa.gov/) (click on
'Request a User ID and Password').

As part of our effort to implement a new safety program for the Center,
we are taking a much more aggressive approach towards Mishaps than has
occurred in the past. We have always captured Mishaps that involved
personal injury, but have been unsuccessful in capturing mission
hardware or other Mishaps. In a recent NASA Inspector General report,
GSFC was cited for not capturing Mishaps in accordance with the NASA
regulations. Additionally, our recent Process Verification Audit reached
the same conclusion. It is apparent that the primary reason for not
capturing this information is due to a lack of understanding about what
a Mishap is and how to report a Mishap. A Centerwide team has been
established to improve our Mishap processes, procedures, and data
systems. In the near future, the Non-Conformance Reporting and
Corrective Action System (NCRCAS) will be updated to provide the single
source for capturing Mishaps as well as Non-Conformances. Until this is
accomplished, we are going to keep relying on the NASA Form 1627 and
document and file the reports manually.

In addition, there is a category of Mishaps, Close Calls, that also
needs to be reported. A Close Call is "An occurrence in which there is
no injury, no equipment/property damage equal to or greater than
\$1,000, and no significant interruption of productive work, but which
possesses a high severity potential for any of the Mishaps defined as
Types A, B, or C Mishaps, Mission Failure or Incident." The same NASA
Form 1627 is used to document these Mishaps, but a block classifying it
as a Close Call is checked.

Enclosed is a copy of the NASA Form 1627 and you should begin to
document mission hardware damage. This includes damage to ground support
equipment and to facilities. If you are unsure whether or not an item
should be documented as a Mishap, you should contact Mr. Jay Garvin at
x6-6490.

At this time, we in Code 300 are going to take the lead in documenting
these types of Mishaps that have historically not been properly
documented; however, as our safety program progresses, the
responsibility will shift from Code 300 personnel to all Center
employees. In accordance with NASA policy, it is the responsibility of
each employee to report Mishaps. Our goal is to set up a simplified,
easy to use, and easy to remember system that will help remove barriers
to our full compliance with Agency regulations. NASA Headquarters and
the Office of Inspector General will be looking to see how well we have
corrected our processes and how well we are implementing this NASA
requirement in the near future.

Charles S. Vanek

Enclosure

# Executive Council

100/Mr. Diaz 500/Mr. Obenschain

100/Dr. Halem 600/Dr. Ormes

100/Ms. Kicza 700/Mr. Hrastar

100/Mr. Townsend 800/Dr. Torres

110/Mr. Simpson 900/Dr. Einaudi

120/Mr. Menchan

130/Ms. Ruff

140/Mr. Watson

150/Ms. Abell

160/Dr. Fahey (Acting)

200/Ms. McNally

300/Mr. Vanek

400/Dr. Campbell