<table style="width:100%;">
<colgroup>
<col style="width: 6%" />
<col style="width: 7%" />
<col style="width: 0%" />
<col style="width: 5%" />
<col style="width: 1%" />
<col style="width: 4%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 5%" />
<col style="width: 2%" />
<col style="width: 6%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 4%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 5%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 4%" />
<col style="width: 1%" />
<col style="width: 10%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="8"><img src="media/image1.png"
style="width:0.65556in;height:0.57014in" /></td>
<td colspan="14"><p>NASA Mishap Report</p>
<p>Part A: Mishap Details</p></td>
<td colspan="11">MASTER FILE NO.</td>
</tr>
<tr class="even">
<td colspan="33">NOTE: FILL IN ALL KNOWN UNSHADED BLOCKS WITHIN 24
HOURS.</td>
</tr>
<tr class="odd">
<td colspan="33"><strong>DETAILS</strong></td>
</tr>
<tr class="even">
<td colspan="2"><p>1. DATE OF INCIDENT</p>
<p><strong>     </strong></p></td>
<td colspan="5"><p>2. TIME OF INCIDENT</p>
<p><strong>     </strong></p></td>
<td colspan="14"><p>3. GENERAL LOCATION <em>(Building, Area, Facility,
etc.)</em></p>
<p><strong>     </strong></p></td>
<td colspan="12"><p>4. EXACT LOCATION <em>(street, floor, room,
etc.)</em></p>
<p><strong>     </strong></p></td>
</tr>
<tr class="odd">
<td colspan="5"><p>5. RESPONSIBLE ORGANIZATION</p>
<p><strong>     </strong></p></td>
<td colspan="8"><p>6. CONTRACT NUMBER</p>
<p><strong>     </strong></p></td>
<td colspan="3"><p>7. ORG. FILE NUMBER</p>
<p><strong>     </strong></p></td>
<td colspan="12"><p>8. ORGANIZATION POINT OF CONTACT</p>
<p><strong>     </strong></p></td>
<td colspan="3"><p>9. MAIL CODE</p>
<p><strong>     </strong></p></td>
<td colspan="2"><p>10. PHONE</p>
<p><strong>     </strong></p></td>
</tr>
<tr class="even">
<td colspan="6"><p>11. MISSION AFFECTED, IF KNOWN</p>
<p><strong>     </strong></p></td>
<td colspan="27"><p>12. PROGRAM IMPACT, IF KNOWN (Describe impact in
terms of delay, cost adjustment, etc.)</p>
<p><strong>     </strong></p></td>
</tr>
<tr class="odd">
<td colspan="33"><p>13. INCIDENT DESCRIPTION <em>(Do not use actual
names, include in the description the sequence of events, extent of
injury or property damage, cause, etc., if known.)</em></p>
<p><strong>     </strong></p></td>
</tr>
<tr class="even">
<td colspan="33"><strong>IMPACT SUMMARY</strong></td>
</tr>
<tr class="odd">
<td colspan="33"><p>14. CHECK ALL OUTCOMES FROM THIS EVENT THAT ARE
KNOWN FACTS <em>(Do not check any box that indicates any future
potential or outcome.)</em></p>
<p> FATALITY SERIOUS DAMAGE TO AIRCRAFT OR SPACE HARDWARE</p>
<p> PERMANENT DISABILITY SERIOUS DAMAGE TO FLIGHT OR GROUND SUPPORT
HARDWARE</p>
<p> 3 OR MORE PEOPLE HOSPITALIZED UNEXPECTED DAMAGE DUE TO TEST
FAILURE</p>
<p> 1 OR 2 PEOPLE HOSPITALIZED DAMAGE ESTIMATE OVER $1,000,000</p>
<p> LOSS OF CONSCIOUSNESS DAMAGE ESTIMATE BETWEEN $250K AND $1M</p>
<p> FULL LOST WORKDAY(S) DAMAGE ESTIMATE BETWEEN $25K AND $250K</p>
<p> RESTRICTED WORKDAY(S) DAMAGE ESTIMATE BETWEEN $1K AND $25K</p>
<p> MEDICATION OR MEDICAL TREATMENT ADMINISTERED DAMAGE ESTIMATE UNDER
$1K</p>
<p> INJURY OR ILLNESS AFFECTED PRIMARY OBJECTIVE(S) OF MISSION</p>
<p> SIGNIFICANT PROGRAM IMPACT</p>
<p> FIRST AID ONLY WAS ADMINISTERED HIGH VISIBILITY (<em>internal or
external to NASA</em>)</p>
<p> CLOSE CALL</p></td>
</tr>
<tr class="even">
<td colspan="33"><p>15. LEVEL OF POTENTIAL FOR THIS EVENT OR CLOSE CALL
<em>(Using reasonable judgment, check the boxes which you believe have a
<u>HIGH</u> probability of occurring under similar conditions.)</em></p>
<p> FATALITY POTENTIAL DAMAGE ESTIMATE OVER $250,000 UNEXPECTED DAMAGE
DUE TO TEST FAILURE</p>
<p> PERMANENT DISABILITY POTENTIAL DAMAGE ESTIMATE UNDER $250,000 AFFECT
PRIMARY OBJECTIVE(S) OF MISSION</p>
<p> 3 OR MORE PEOPLE HOSPITALIZED SERIOUS DAMAGE TO AIRCRAFT OR SPACE
HARDWARE SIGNIFICANT PROGRAM IMPACT<em>)</em></p>
<p> FULL LOST WORKDAY(S) SERIOUS DAMAGE TO FLIGHT OR GROUND SUPPORT
HARDWARE HIGH VISIBILITY (i<em>nternal or external to
NASA)</em></p></td>
</tr>
<tr class="odd">
<td colspan="33"><strong>PERSON INVOLVED IN INJURY OR
ILLNESS</strong></td>
</tr>
<tr class="even">
<td colspan="10"><p>16. NAME <em>(Last, First MI)</em></p>
<p><strong>     </strong></p></td>
<td colspan="8"><p>17. ORGANIZATION</p>
<p><strong>     </strong></p></td>
<td colspan="6"><p>18. CONTRACT NUMBER</p>
<p><strong>     </strong></p></td>
<td colspan="9"><p>19. JOB TITLE/OCCUPATION</p>
<p><strong>     </strong></p></td>
</tr>
<tr class="odd">
<td colspan="9"><p>20. SUPERVISOR’S NAME <em>(Full Name)</em></p>
<p><strong>     </strong></p></td>
<td colspan="8"><p>21. SUPERVISOR’S ORGANIZATION</p>
<p><strong>     </strong></p></td>
<td colspan="9"><p>22. SUPERVISOR’S MAIL CODE</p>
<p><strong>     </strong></p></td>
<td colspan="7"><p>23. SUPERVISOR’S PHONE</p>
<p><strong>     </strong></p></td>
</tr>
<tr class="even">
<td><p>24. AGE</p>
<p><strong>  </strong></p></td>
<td colspan="3"><p>25. SEX</p>
<p> Male Female</p></td>
<td colspan="7"><p>26. SHIFT WORKED</p>
<p>1st 2nd 3rd</p></td>
<td colspan="7"><p>27. CONTINUOUS DUTY HOURS</p>
<p><strong>  </strong></p></td>
<td colspan="15"><p>28. YEARS OF EXPERIENCE</p>
<p> Under 1 Under 5 Under 10 Over 10</p></td>
</tr>
<tr class="odd">
<td colspan="3"><p>29. INJURY OR ILLNESS</p>
<p> INJURY ILLNESS</p></td>
<td colspan="7"><p>30. FROM PRE-EXISTING</p>
<p> YES NO</p></td>
<td colspan="9"><p>31. FATALITY? 32. DATE OF DEATH</p>
<p> <strong>     </strong></p></td>
<td colspan="4"><p>33. PERMANENT</p>
<p>DISABILITY?</p></td>
<td colspan="7"><p>34. # OF FULL LOST</p>
<p>WORKDAYS</p>
<p><strong>     </strong></p></td>
<td colspan="3"><p>35. # OF RESTRICTED</p>
<p>WORKDAYS</p>
<p><strong>     </strong></p></td>
</tr>
<tr class="even">
<td colspan="15"><p>36. INJURY TYPE(S) <em>(e.g., Abrasion, Burn,
Concussion, Laceration, etc.)</em></p>
<p><strong>     </strong></p></td>
<td colspan="18"><p>37. AFFECTED BODY PART(S) OR BODY SYSTEM(S)</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="33"><p>38. BRIEF MEDICAL DIAGNOSIS</p>
<p><strong>     </strong></p></td>
</tr>
<tr class="even">
<td colspan="33"><p>39. MEDICAL TREATMENT ADMINISTERED</p>
<p> TREATMENT OF INFECTION APPLICATION OF SUTURES REMOVAL OF OBJECT IN
WOUND</p>
<p> APPLICATION OF ANTISEPTIC USE OF BUTTERFLY ADHESIVE USE OF
PRESCRIPTION MEDICATION</p>
<p> 2ND OR 3RD DEGREE BURN(S) REMOVAL OF FOREIGN OBJECT(S) HOT OR COLD
SOAKING/COMPRESS THERAPY</p>
<p> CUT AWAY DEAD SKIN USE OF HEAT THERAPY USE OF WHIRLPOOL BATH
THERAPY</p>
<p> POSITIVE X-RAY DIAGNOSIS ADMISSION TO HOSPITAL FOR MORE THAN
OBSERVATION FIRST AID ONLY</p></td>
</tr>
<tr class="odd">
<td colspan="33"><p>40. OTHER MEDICAL TREATMENT ADMINISTERED</p>
<p><strong>     </strong></p></td>
</tr>
<tr class="even">
<td colspan="33"><strong>EQUIPMENT/PROPERTY DAMAGED</strong></td>
</tr>
<tr class="odd">
<td colspan="14"><p>41. CLASS OF EQUIPMENT/PROPERTY DAMAGED</p>
<p> FLIGHT HARDWARE AIRCRAFT</p>
<p> GROUND SUPPORT EQUIPMENT OTHER</p>
<p> FACILITY</p>
<p> PRESSURE VESSEL</p>
<p> MOTOR VEHICLE</p></td>
<td colspan="13"><p>42. ESTIMATED COST OF ALL DAMAGED ITEMS</p>
<p> OVER $1,000,000</p>
<p> BETWEEN $250K AND $1M</p>
<p> BETWEEN $25K AND $250K</p>
<p> BETWEEN $1K AND $25K</p>
<p> UNDER $1,000</p></td>
<td colspan="6"><p>43. # OF ITEMS DAMAGED</p>
<p><u>     </u></p></td>
</tr>
<tr class="even">
<td colspan="33"><p>43. SPECIFIC ITEM(S) DAMAGED</p>
<p><strong>     </strong></p></td>
</tr>
<tr class="odd">
<td colspan="33"><strong>SUBMITTER</strong></td>
</tr>
<tr class="even">
<td colspan="12"><p>44. SUBMITTED BY <em>(Full Name)</em></p>
<p><strong>     </strong></p></td>
<td colspan="8"><p>45. ORGANIZATION</p>
<p><strong>     </strong></p></td>
<td colspan="5"><p>46. MAIL CODE</p>
<p><strong>     </strong></p></td>
<td colspan="4"><p>47. PHONE</p>
<p><strong>     </strong></p></td>
<td colspan="3"><p>48. DATE</p>
<p><strong>     </strong></p></td>
<td><p>49. TIME</p>
<p><strong>     </strong></p></td>
</tr>
</tbody>
</table>

**NF 1627** MAR 2001 PREVIOUS EDITIONS ARE OBSOLETE.

<table>
<colgroup>
<col style="width: 12%" />
<col style="width: 1%" />
<col style="width: 12%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 19%" />
<col style="width: 12%" />
<col style="width: 0%" />
<col style="width: 13%" />
<col style="width: 9%" />
<col style="width: 10%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="4"><img src="media/image1.png"
style="width:0.65556in;height:0.57014in" /></td>
<td colspan="4"><p>NASA Mishap Report</p>
<p>Part B: Causes and Corrective Action</p></td>
<td colspan="3">MASTER FILE NO.</td>
</tr>
<tr class="even">
<td colspan="11"><strong>CAUSES</strong></td>
</tr>
<tr class="odd">
<td colspan="5"><p>50. WHAT WAS THE DIRECT CAUSE(S)</p>
<p>     </p></td>
<td colspan="2"><p>51. WHAT OBJECTS OR SUBSTANCES WERE INVOLVED</p>
<p>     </p></td>
<td colspan="4"><p>52. WHAT ACTIVITIES OR UNSAFE ACTS WERE IN
PROGRESS</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="11"><strong>INITIAL CORRECTIVE ACTION</strong></td>
</tr>
<tr class="odd">
<td colspan="11"><p>53. <strong><u>INITIAL</u></strong> ACTION TAKEN
<em>(Summarize all corrective action taken)</em></p>
<p><strong>     </strong></p></td>
</tr>
<tr class="even">
<td><p>54. DATE INITIATED</p>
<p><strong>     </strong></p></td>
<td colspan="2"><p>55. DATE COMPLETED</p>
<p><strong>     </strong></p></td>
<td colspan="3"><p>56. PERSON TAKING ACTION <em>(Full Name)</em></p>
<p><strong>     </strong></p></td>
<td colspan="3"><p>57. ORGANIZATION</p>
<p><strong>     </strong></p></td>
<td><p>58. MAIL CODE</p>
<p><strong>     </strong></p></td>
<td><p>59. PHONE</p>
<p><strong>     </strong></p></td>
</tr>
<tr class="odd">
<td colspan="11"><strong>PLANNED CORRECTIVE ACTION</strong></td>
</tr>
<tr class="even">
<td colspan="11"><p>60. <strong><u>PROPOSED</u></strong> ACTION TO BE
TAKEN <em>(Summarize any future action to be taken.)</em></p>
<p><strong>     </strong></p></td>
</tr>
<tr class="odd">
<td colspan="2"><p>61. EST. START DATE</p>
<p><strong>     </strong></p></td>
<td><p>62. EST. COMPL.</p>
<p><strong>     </strong></p></td>
<td colspan="3"><p>63. PERSON TAKING ACTION <em>(Full Name)</em></p>
<p><strong>     </strong></p></td>
<td colspan="3"><p>64. ORGANIZATION</p>
<p><strong>     </strong></p></td>
<td><p>65. MAIL CODE</p>
<p><strong>     </strong></p></td>
<td><p>66. PHONE</p>
<p><strong>     </strong></p></td>
</tr>
<tr class="even">
<td colspan="11"><p>67. <strong><u>PROPOSED</u></strong> ACTION TO BE
TAKEN <em>(Summarize any future action to be taken.)</em></p>
<p><strong>     </strong></p></td>
</tr>
<tr class="odd">
<td colspan="2"><p>68. EST. START DATE</p>
<p><strong>     </strong></p></td>
<td><p>69. EST. COMPL.</p>
<p><strong>     </strong></p></td>
<td colspan="3"><p>70. PERSON TAKING ACTION <em>(Full Name)</em></p>
<p><strong>     </strong></p></td>
<td colspan="3"><p>71. ORGANIZATION</p>
<p><strong>     </strong></p></td>
<td><p>72. MAIL CODE</p>
<p><strong>     </strong></p></td>
<td><p>73. PHONE</p>
<p><strong>     </strong></p></td>
</tr>
</tbody>
</table>

**NF 1627** MAR 2001 PREVIOUS EDITIONS ARE OBSOLETE.

Instructions

Complete the initial incident report (unshaded portions) and submit to
your local NASA Safety Office within 24 hours of the incident
occurrence. Complete and submit the follow-up report (with shaded areas)
within ten working days of the incident. Retain a copy for your own
files.

**Working With This Form**

This electronic document is a form. It has fields where you can enter
information. You can use the mouse or TAB key to move between fields.
The TAB key moves to the next field and SHIFT-TAB moves backwards. Some
fields control the types of data that you can enter.

You should fill in this form electronically and send it to your local
NASA Safety Office by electronic mail.

DETAILS

1\. DATE OF INCIDENT - Enter date of the incident in MM/DD/YYYY format.
Example: 6/1/2001.

2\. TIME OF INCIDENT - Enter time of the incident using 24-hour clock.
Examples: 09:30 for 9:30 AM or 14:15 for 2:15 PM.

3\. GENERAL LOCATION - Identify the building, area, or facility where
the incident occurred.

4\. EXACT LOCATION - Describe the exact location of the incident.
Example: Third floor, far west corridor.

5\. RESPONSIBLE ORGANIZATION - Enter complete name of organization that
is reporting the incident.

6\. CONTRACT NUMBER - When the organization is a contractor, enter the
contract number.

7\. ORGANIZATION FILE NUMBER - Assign file number using your
organization\'s unique four-character code, the mishap number
(sequential) using four digits, and the fiscal year using two digits.
Example: EGB1-0001-89.

8 - 10. ORGANIZATION POINT OF CONTACT, MAIL CODE, PHONE - Identify the
person to contact at the organization.

11\. MISSION AFFECTED - Enter the name or number of the mission,
program, or project affected by the mishap. Examples: STS-32; Delta 181.

12\. PROGRAM IMPACT - Describe the effect on the mission, program, or
project in terms of delay or significant cost adjustment. Example:
Two-week launch delay.

13\. INCIDENT DESCRIPTION - Describe the event including information
about the extent of damage and/or injury, conditions that led to the
mishap, and cause if known at this time. Specify location of facility
where medical treatment was provided. DO NOT include names of persons.

IMPACT SUMMARY

14\. ACTUAL OUTCOMES - Mark every checkbox that represents current facts
about the incident.

15\. LEVEL OF POTENTIAL - Mark every checkbox that represents likely
outcomes for the incident.

PERSONNEL INVOLVED IN INJURY OR ILLNESS

(If more than one person was injured, then attach a NASA Mishap Report
(NF 1627) with only this section completed for each additional person.)

16\. NAME - Self-explanatory.

17\. ORGANIZATION - Identify the organization of the person involved.

18\. CONTRACT NUMBER - When the organization is a contractor, enter the
contract number.

19\. JOB TITLE/OCCUPATION - Describe the job position of the person
involved.\
Example: Technician

20-23. SUPERVISOR'S NAME, ORGANIZATION, MAIL CODE, & PHONE - Provide
identifying information about the supervisor of the person involved.

24\. AGE - (of the person involved) Self-explanatory.

25\. SEX - Check as appropriate.

26\. SHIFT WORKED - Check as appropriate.

27\. CONTINUOUS DUTY HOURS - Self-explanatory.

28\. YEARS OF EXPERIENCE - Check as appropriate.

29\. INJURY OR ILLNESS - Check as appropriate.

30\. FROM PRE-EXISTING - Check as appropriate.

31\. FATALITY? -

32\. DATE OF DEATH -

33\. PERMANENT DISABILITY?

34\. \# OF FULL LOST WORKDAYS -

35\. \# OF RESTRICTED WORKDAYS -

36\. INJURY TYPE(S) - Choose one or more items from the list. (See
instructions below.)

37\. AFFECTED BODY PART(S) or BODY SYSTEM(S) - Choose one or more items
from the list. (See instructions below.)

38\. BRIEF MEDICAL DIAGNOSIS -

39\. MEDICAL TREATMENT ADMINISTERED - Mark every checkbox that
represents treatment administered to the person involved. Mark the
checkbox for "First Aid Only" if only First Aid treatment was
administered to the individual.

40\. MEDICAL TREATMENT ADMINISTERED - Describe any treatment not
included in box #39.

EQUIPMENT/PROPERTY DAMAGE

41\. CLASS OF EQUIPMENT/PROPERTY DAMAGED - Mark every checkbox that
represents the type of damaged.

42\. ESTIMATED COST OF ALL DAMAGED ITEMS - Mark one checkbox that
represents the initially estimated cost of the damage. Provide Final
Cost in follow-up report.

43\. \# OF ITEMS DAMAGED -

43\. SPECIFIC ITEM(S) DAMAGED - Identify or describe the damaged items
from box #41.\
Example: If the class indicated in box #41 is Flight Hardware, then the
specific item could be \"Orbiter/Avionics.\"

SUBMITTER

44-47. SUBMITTED BY, ORGANIZATION, MAIL CODE, & PHONE - Provide
identifying information about the person filling in this form.

48-49. DATE & TIME - Enter the date and time when the form is filled in.

CAUSES

50\. DIRECT CAUSE(S) - Choose one or more items from the list. (See
instructions below.)

51\. OBJECTS OR SUBSTANCES INVOLVED - Choose one or more items from the
list. (See instructions below.)

52\. ACTIVITIES OR UNSAFE ACTS IN PROGRESS - Choose one or more items
from the list. (See instructions below.)

INITIAL CORRECTIVE ACTION

53\. INITIAL ACTION TAKEN -

54\. DATE INITIATED -

55\. DATE COMPLETED -

56-59. PERSON TAKING ACTION, ORGANIZATION, MAIL CODE, & PHONE - Provide
identifying information about the person taking the initial corrective
action.

PLANNED CORRECTIVE ACTION

60\. PLANNED ACTION TO BE TAKEN -

61\. ESTIMATED START DATE -

62\. ESTIMATED COMPLETION -

63-66. PERSON TAKING ACTION, ORGANIZATION, MAIL CODE, & PHONE - Provide
identifying information about the person taking the planned corrective
action.

67\. PLANNED ACTION TO BE TAKEN -

68\. ESTIMATED START DATE -

69\. ESTIMATED COMPLETION -

70-73. PERSON TAKING ACTION, ORGANIZATION, MAIL CODE, & PHONE - Provide
identifying information about the person taking the planned corrective
action.

**Choosing items from a list**

The list appears when you move the insertion point to this field. If the
field already has data, then clicking with the mouse might not display
the list again. In this case, click in an earlier field and use the TAB
key to move forward and display the list.

To choose an item from the list first highlight the item you want. You
can use the arrow keys or the mouse to highlight the proper item. Then
either press the ENTER key, click the Ok button, or double click the
item.

The list of items you have chosen is displayed at the top of the window.
You can add many items to the list. To remove any item, you must edit
the list with the DELETE or BACKSPACE keys. You can edit the list in the
list window or you can edit the field on the form.