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**NASA Procedural Requirements**

**NPR: 8621.1B**

**Effective Date: May 23, 2006**

**Expiration Date: May 23, 2011**

**NASA Procedural Requirements for Mishap and Close Call Reporting,
Investigating, and Recordkeeping**

Responsible Office: Office of Safety and Mission Assurance

**NASA Procedural Requirements**

####### 

####### **NPR: 8621.1B**

**Effective Date: May 23, 2006**

**Expiration Date: May 23, 2011**

**NASA Procedural Requirements for Mishap and Close Call Reporting,
Investigating, and Recordkeeping**

**Responsible Office: Office of Safety and Mission Assurance**

**TABLE OF CONTENTS**

**[Cover]{.underline}**

**[Change History]{.underline}**

**[Preface]{.underline}**

P.1 PURPOSE

P.2 APPLICABILITY

P.3 AUTHORITY

P.4 REFERENCES

P.5 CANCELLATION

**[CHAPTER 1. General Information]{.underline}**

1.1 Objectives of NASA Mishap and Close Call Investigations

1.2 Description of NASA Mishaps and Close Calls

1.3 Determining the Classification Level and Type of Investigation to be
Conducted

1.4 Roles and Responsibilities

1.5 Notification and Reporting Requirements

1.6 Additional Notification and Reporting Requirements for Aircraft
Investigations

1.7 Investigation Product for each Classification Level/Type of
Investigation

1.8 Recording Requirements

1.9 Collateral Investigations

1.10 Investigations by Outside Authorities

**[CHAPTER 2. Readiness to Conduct Investigations]{.underline}**

2.1 Headquarters Operations and Center Mishap Preparedness and
Contingency Plan

2.2 Program and Project Mishap Preparedness and Contingency Plans

2.3 Mishap Preparedness and Contingency Plan Practice

2.4 Contingency Plan Web Site

2.5 Contract Clauses

2.6 Training

2.7 Tools

**[CHAPTER 3. Initial Response to a Mishap or Close Call]{.underline}**

3.1 Safe the Mishap Site and Initiate Mishap Preparedness and
Contingency Plan(s)

3.2 Notify Headquarters Office of Safety and Mission Assurance within 1
Hour of Type A Mishap, Type B Mishap, High-Visibility Mishap, or
High-Visibility Close Call

3.3 Deploy IRT

3.4 Notify Personnel and the Public of Potential Hazards

3.5 Secure the Site and Preserve Evidence

3.6 Impound Data

3.7 Initiate Drug Testing

3.8 Collect Witness Statements

3.9 Coordinate Release of Information

3.10 Notify OSHA

3.11 Record the Mishap

**[CHAPTER 4. Select the Investigating Authority and
Support]{.underline}**

4.1 Determine the Appointing Official for Mishap and Close Call
Investigation

4.2 Select the Members of the Investigating Authority (MIB, MIT, or MI)

4.3 Select the Ex Officio

4.4 Select Investigating Authority\'s Advisors

4.5 Select Investigating Authority\'s Consultants

4.6 Provide Support to Investigating Authority

4.7 Contents of the Appointment Letter or Appointment Orders

**[CHAPTER 5. Mishap Investigation Process]{.underline}**

5.1 Overview of the Mishap Investigation Process

5.2 Prepare for the Investigation

5.3 Verify that the Site is Safe and Secured and Ensure Evidence is
Preserved/Impounded

5.4 Gather Physical Evidence and Facts

5.5 Interview Witnesses

5.6 Review and Analyze Data

5.7 Draw Conclusions and Document Findings

5.8 Generate Recommendations

5.9 When and How to Turn Over for Criminal Investigation

5.10 Release the Mishap Site and Restore Site Operations

**[CHAPTER 6. Mishap Report]{.underline}**

6.1 Develop the Mishap Report

6.2 Release Investigating Authority

6.3 Review, Endorse, and Approve Mishap Report

6.4 Authorize Mishap Report for Public Release

6.5 Distribute Mishap Report

**[CHAPTER 7. Post-Investigation Activities]{.underline}**

7.1 Develop CAP

7.2 CAP Contents

7.3 Review and Approve CAP

7.4 Implement CAP

7.5 Monitor and Closeout CAP

7.6 Develop, Disposition, Submit, and Approve Lessons Learned

7.7 Conclude Mishap Activities

7.8 Record and Retain Evidence

**[APPENDICES]{.underline}**

Appendix A. Terms and Definitions

Appendix B. Acronyms

Appendix C. Mishap Investigation Notional Time Line

**[LIST OF FIGURES]{.underline}**

Figure 1. Mishap Classification Levels and Type of Investigation to be
Conducted

Figure 2. Mishap Organizational Responsibilities Matrix

Figure 3. NTSB Reportable Events (Per 49 CFR Part 830)

Figure 4. Information Required for All Agency Aircraft Mishaps and Close
Calls

Figure 5. Classification Level/Investigation Type with Corresponding
Appointing Official, Endorsing Officials, and Required Products in the
Mishap Report

Figure 6. Statement that Shall Be Read to Witness at the Start of
His/Her Formal Interview

Figure 7. Typical Steps in the Mishap Investigation

**Change History**

**NPR 8621.1B, NASA Procedural Requirements for Mishap and Close Call
Reporting, Investigating, and Recordkeeping**

  ----- -------- --------------------------------------------------------
  1     August   Administrative corrections to remove typographical
        31, 2006 errors. Update to requirement for CDs and AA/OIA to
                 report mishaps to the Administrator (paragraph 1.4.7)

  2     May 18,  Administrative corrections for clarification for
        2007     paragraph 1.4.5.d, 1.4.5.c, 1.4.7.e, 1.4.7.f, 1.7.3,
                 definitions, and Mishap organizational responsibilities
                 matrix
  ----- -------- --------------------------------------------------------

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**Preface**

**P.1 PURPOSE**

a\. The purpose of this NASA Procedural Requirements (NPR) is to provide
requirements to report, investigate, and document mishaps, close calls,
and previously unidentified serious workplace hazards to prevent
recurrence of similar accidents. This NPR does not apply to
investigative procedures concerning civil, criminal, or administrative
culpability or legal liability. Furthermore, the safety investigation
outlined in this NPR shall not be used to direct or justify disciplinary
action for mishaps or close calls (Requirement 30984).

b\. This NPR provides requirements that specify how to respond to any
mishap or close call from discovery through corrective action and
closure. It contains requirements for classifying mishaps, establishing
investigation authorities, and performing investigations. It formalizes
notification, analysis, and reporting obligations; describes roles and
responsibilities; provides instruction on release of information to the
public; and specifies the relationship and interaction with the
Occupational Safety and Health Administration (OSHA), the National
Transportation Safety Board (NTSB), and other government agencies.

**P.2 APPLICABILITY**

a\. This NPR is applicable to NASA Headquarters and Centers, including
Component Facilities; the Jet Propulsion Laboratory, and other NASA
contractors and grantees as specified in their contracts or grants; and
to other organizations (i.e., commercial partners, other Federal
agencies, international parties, and tenants on Centers) as specified
and described in written operating agreements. This NPR is applicable to
mishaps and close calls for NASA-funded activities at any government,
contractor, subcontractor, or grantee site.

b\. The concept of word usage and intended meaning is as follows:
\"Shall\" has been used only when application of a procedure is a
mandatory requirement. \"Should\" has been used only when application of
a procedure is recommended.

**P.3 AUTHORITY**

a\. 29 CFR Part 1904, Recording and Reporting Occupational Injuries and
Illnesses (U.S. Department of Labor, Occupational Safety and Health
Administration).

b\. 29 CFR Part 1960, Basic Program Elements for Federal Employee
Occupational Safety and Health Programs and Related Matters.

c\. 49 CFR Part 830, Notification and Reporting of Aircraft Accident or
Incidents and Overdue Aircraft, and Preservation of Aircraft Wreckage,
Mail, Cargo, and Records.

d\. 42 U.S.C. 2473 (c)(1), Section 203 (c)(1) of the National
Aeronautics and Space Act of 1958, as amended.

e\. 29 U.S.C. 668, Section 19 of the Occupational Safety and Health Act
of 1970, as amended.

f\. Inspector General Act of 1978, as amended, 5 U.S.C. App. 3.

g\. NPD 8700.1, NASA Policy for Safety and Mission Success.

**P.4 REFERENCES**

a\. NPD 9800.1, NASA Office of Inspector General Programs.

b\. NPR 1441.1, NASA Records Retention Schedules (Schedule 1).

c\. NPR 1600.1, NASA Security Program Procedural Requirements.

d\. NPR 7120.5, NASA Program and Project Management Processes and
Requirements.

e\. NPR 3792.1, Plan for a Drug-Free Workplace.

f\. NASA Federal Acquisition Regulation (FAR) Supplement (NFS) Part
1807, Acquisition Planning.

g\. NFS Part 1852.223-70, Safety and Health.

h\. Publication L. 109-155, Sec. 821, NASA Authorization Act of 2005;
Human Space Flight Independent Investigation Commission.

i\. Incident Reporting Information System (IRIS).

j\. NASA Lessons Learned Information System (LLIS)
(<http://llis.gsfc.nasa.gov/>).

**P.5 CANCELLATION**

NPR 8621.1, dated June 2, 2000.

/s/

Bryan O\'Connor

Chief, Safety and Mission Assurance

DISTRIBUTION:

NODIS

**CHAPTER 1. General Information**

**1.1 Objectives of NASA Mishap and Close Call Investigations**

The objective of mishap and close call investigations is to improve
safety by identifying what happened, where it happened, when it
happened, why it happened, and what should be done to prevent recurrence
and reduce the number and severity of mishaps.

**1.2 Description of NASA Mishaps and Close Calls**

1.2.1 NASA Mishap. An unplanned event that results in at least one of
the following:

1.2.1.1 Injury to non-NASA personnel, caused by NASA operations.

1.2.1.2 Damage to public or private property (including foreign
property), caused by NASA operations or NASA-funded development or
research projects.

1.2.1.3 Occupational injury or occupational illness to NASA personnel.

1.2.1.4 NASA mission failure before the scheduled completion of the
planned primary mission.

1.2.1.5 Destruction of, or damage to, NASA property.

1.2.2 The following are **not** considered NASA mishaps.

1.2.2.1 A malfunction or failure of component parts that are normally
subject to fair wear and tear and have a fixed useful life that is less
than the fixed useful life of the complete system or unit of equipment,
provided that all of the following are true:

a\. There was adequate preventative maintenance.

b\. The malfunction or failure was the only damage, and the sole action
is to replace or repair that component. (This exception does not apply
to a malfunction or failure of a component part that results in damage
to another component or the facility or injury to personnel.)

1.2.2.2 A test failure involving damage to equipment or property as a
result of testing, provided that **all** of the following are true:

a\. The test article is not flight hardware.

b\. The testing is part of an authorized
research/development/qualification/certification program.

c\. Damage is limited to the test article and test instrumentation.

d\. Risk of damage to the test article and test instrumentation
resulting from failure was accepted explicitly (i.e., documented) by
program/project management and concurred on by the Center safety office.

e\. The test team performs a test failure analysis and generates a
technical report instead of treating it as a mishap and completing a
mishap report.

1.2.2.3 A failure resulting in damage to [flight hardware]{.underline}
during the ground Acceptance Test Procedure (ATP) is not a mishap when
**all** of the following are true:

a\. The failure is a predictable outcome.

b\. Only the flight article is damaged or failed, and testing did not
damage the test stand or facility or cause personnel injury.

c\. The test equipment functioned properly.

d\. There were no anomalies in the facility or test procedures that
could have contributed to the article failure.

e\. The test team performs a test failure analysis that identifies the
root cause(s) of the failure and generates a technical report instead of
treating it as a mishap and completing a mishap report.

1.2.2.4 Destruction of, or damage to, any property (public, private, or
government) on a Center or involving NASA property outside the Center's
gates, as a direct result of **only** the following weather conditions:
hurricane, lightning, tornado, tidal wave, tsunami, water spout ice/snow
loads (e.g., on electrical wires).

> *Note: In these cases, the weather is the initiating event (proximate
> cause) for the mishap. If the weather was an intermediate cause or a
> contributing factor to a mishap, this exemption to "mishap
> classification" would not apply.*

1.2.2.5 Destruction of, or damage to, any property (public, private, or
government) on a Center or involving NASA property outside the Center's
gates, as a direct result of a natural phenomenon **such as** a flood,
landslide, earthquake, meteoroid landing, or volcanic eruption.

> *Note: In these cases, the natural phenomenon is the initiating event
> (proximate cause) for the mishap. If the natural phenomena was an
> intermediate cause of an incident or contributed to a mishap, this
> exemption to "mishap classification" would not apply.*

1.2.2.6 When an event is not considered a mishap because the initiating
event (proximate cause) is natural phenomenon or weather, the cognizant
Center safety office shall enter the event and a description of the
damage in IRIS. (Requirement).

> *Note: Close calls involving aircraft may be entered into the NASA
> Aviation Anomaly Reporting System (NAARS) in lieu of IRIS.*
>
> *Note: The cognizant Center safety office is the safety office of the
> Center that hosts the project or that has been assigned Safety and
> Mission Assurance (SMA) responsibilities for the program.*
>
> *Note: NASA classifies all weather and natural phenomena as "Acts of
> Nature" in IRIS.*
>
> *Incident Category: \"Incident\"*
>
> *Incident Type: \"Acts of Nature \"*
>
> *Incident subtype: \" wind, rain, snow, lightning, earthquake\"*
>
> *Classification: \"Non-NPR 8621.1 issue\"*

1.2.2.7 When an event is not considered a mishap because the initiating
event (proximate cause) is natural phenomenon or weather, the
organization incurring the damage shall perform a technical assessment
to evaluate design and construction aspects, contingency planning, and
emergency response and provide facts, findings, and recommendations to
the Center Director through the Center SMA Director (or equivalent
office with responsibilities for the Center's facility safety program)
(Requirement).

1.2.2.8 NASA property damage or personnel injuries that are the result
of vandalism, riots, civil disorders, or felonious acts such as arson or
sabotage are not considered NASA mishaps. These incidents should be
reported and investigated in accordance with procedures under NPD
9800.1, NASA Office of Inspector General Programs, and NPR 1600.1, NASA
Security Program Procedural Requirements.

1.2.3 Close Call. An event in which there is no injury or only minor
injury requiring first aid and/or no equipment/property damage or minor
equipment/property damage (less than \$1000), but which possesses a
potential to cause a mishap.

**1.3 Determining the Classification Level and Type of Investigation to
be Conducted**

1.3.1 The severity of the personnel injury and the direct cost of the
mishap or close call (property damage and/or mission failure) shall
determine the classification level of the mishap or close call (see
Figure 1) and the corresponding type of investigation to be conducted
(Requirement 31069).

1.3.2 When the Administrator, Associate Administrator (AA), Mission
Directorate Associate Administrator (MDAA), Chief Office of Safety and
Mission Assurance (Chief/OSMA), the Designated Agency Safety and Health
Official (DASHO), Center Director (CD), or the Assistant Administrator,
Office of Infrastructure and Administration (AA/OIA), believes that the
mishap or close call is a high-visibility event, he/she may elevate the
mishap classification level of investigation to the classification
he/she deems appropriate and request the appropriate appointing official
to form a Mishap Investigation Board (MIB).

1.3.3 Determining the direct cost of the mishap or close call (for the
purpose of mishap classification).

1.3.3.1 The responsible manager, with review and concurrence by the
Center safety office, shall calculate the direct cost of a mishap or
close call by adding all the actual costs (or the estimate of the cost)
(the greater value of actual or fair market value) of damaged property,
destroyed property, or mission failure, actual cost of repair or
replacement, labor (actual value of replacement or repair hours for
internal and external/contracted labor), cost of the lost commodity
(e.g., the cost of the fluid that was lost from a ruptured pressure
vessel), as well as resultant costs such as environmental
decontamination, property cleanup, and restoration (Requirement 31072).

1.3.3.2 In cases where replacement parts are available from salvaged or
excess equipment at little or no cost to NASA, the direct cost of the
mishap or close call shall include the actual costs of replacement parts
(if they were purchased new) plus labor calculated as if the
salvage/excess parts were unavailable (Requirement 31073).

1.3.3.3 In cases where insurance compensation, contractor compensation,
or other compensation is available or provided, the direct cost of the
mishap or close call shall include the direct cost (or estimate of the
cost) as if this compensation were [not]{.underline} available or
provided (Requirement 31074).

1.3.3.4 The cost of the safety mishap investigation shall not be
included in the direct cost (Requirement 31075).

Figure 1. Mishap Classification Levels and Type of Investigation to be
Conducted

+----------+---------------------------+------------------------------+
| *        | **[Property               | **[Injury]{.underline}**     |
| *[Classi | Damage]{.underline}**     |                              |
| fication |                           |                              |
| Level &  |                           |                              |
| Inves    |                           |                              |
| tigation |                           |                              |
| Typ      |                           |                              |
| e]{.unde |                           |                              |
| rline}** |                           |                              |
+----------+---------------------------+------------------------------+
| **Type A | Total direct cost of      | Occupational injury and/or   |
| Mishap** | mission failure and       | illness that resulted in:    |
|          | property damage is        |                              |
|          | \$1,000,000 or more,      | A fatality,                  |
|          |                           |                              |
|          | ***or***                  | ***or***                     |
|          |                           |                              |
|          | Crewed aircraft hull loss | A permanent total            |
|          | has occurred,             | disability,                  |
|          |                           |                              |
|          | ***or***                  | ***or***                     |
|          |                           |                              |
|          | Occurrence of an          | The hospitalization for      |
|          | unexpected aircraft       | inpatient care of 3 or more  |
|          | departure from controlled | people within 30 workdays of |
|          | flight (except high       | the mishap.                  |
|          | performance jet/test      |                              |
|          | aircraft such as F-15,    |                              |
|          | F-16, F/A-18, T-38,       |                              |
|          | OV-10, and T-34, when     |                              |
|          | engaged in flight test    |                              |
|          | activities).              |                              |
+----------+---------------------------+------------------------------+
| **Type B | Total direct cost of      | Occupational injury and/or   |
| Mishap** | mission failure and       | illness has resulted in      |
|          | property damage of at     | permanent partial            |
|          | least \$250,000 but less  | disability.                  |
|          | than \$1,000,000.         |                              |
|          |                           | ***or***                     |
|          |                           |                              |
|          |                           | The hospitalization for      |
|          |                           | inpatient care of 1-2 people |
|          |                           | within 30 workdays of the    |
|          |                           | mishap.                      |
+----------+---------------------------+------------------------------+
| **Type C | Total direct cost of      | Nonfatal occupational injury |
| Mishap** | mission failure and       | or illness that caused any   |
|          | property damage of at     | workdays away from work,     |
|          | least \$25,000 but less   | restricted duty, or transfer |
|          | than \$250,000.           | to another job beyond the    |
|          |                           | workday or shift on which it |
|          |                           | occurred.                    |
+----------+---------------------------+------------------------------+
| **Type D | Total direct cost of      | Any nonfatal OSHA recordable |
| Mishap** | mission failure and       | occupational injury and/or   |
|          | property damage of at     | illness that does not meet   |
|          | least \$1,000 but less    | the definition of a Type C   |
|          | than \$25,000.            | mishap.                      |
+----------+---------------------------+------------------------------+
| **Close  | An event in which there   | An event in which there is   |
| Call**   | is no equipment/property  | no injury or only minor      |
|          | damage or minor           | injury requiring first aid,  |
|          | equipment/property damage | but which possesses a        |
|          | (less than \$1000), but   | potential to cause a mishap. |
|          | which possesses a         |                              |
|          | potential to cause a      |                              |
|          | mishap.                   |                              |
+----------+---------------------------+------------------------------+

**1.4 Roles and Responsibilities**

1.4.1 Administrator. The Administrator:

a\. May elect to be the appointing official for Type A mishaps or
delegate to the AA. (If the Administrator elects not to be the
appointing official, the MDAA, CD, or another designee will serve as the
appointing official.) (Requirement 31078).

b\. Shall serve as appointing official for NASA joint participation on a
MIB with the Department of Defense (DoD) and other agencies unless
authority is delegated by existing agreements (Requirement 31079).

c\. May elect to be an endorsing official for Type A mishaps and other
mishaps in which he/she is the appointing official.

1.4.2 Chief/OSMA. The Chief/OSMA or designee shall:

a\. Ensure the proper reporting, investigating, and recordkeeping for
mishaps and close calls by defining the mishap reporting and
investigating process, updating this NPR, verifying its implementation,
developing mishap investigation training, and identifying candidate
mishap investigation tools (Requirement 31082).

b\. Concur with the mishap classification level, investigation approach,
and the MIB membership and serve as an endorsing official for the mishap
report for Type A mishaps, Type B mishaps, high-visibility mishaps, and
high-visibility close calls (Requirement 31083).

c\. Provide a qualified NASA person to support NTSB investigations of
NASA aircraft mishaps (Requirement 17014).

[]{.mark}

d\. Archive NASA Headquarters-approved NASA mishap investigation board
reports and related documents per NPR 1441.1 (Requirement 17015).

1.4.3 Inspector General. The Inspector General shall investigate
criminal activity associated with mishaps and close calls (Requirement
31084).

1.4.4 AA. The AA shall:

a\. Serve as the appointing official for Type A mishaps if designated by
the Administrator (Requirement 31090).

b\. Obtain concurrence from the Chief/OSMA and the Chief Engineer on the
MIB membership of mishaps in which he/she is the appointing official
(Requirement 31092).

c\. Serve as an endorsing official for all mishaps in which he/she is
the appointing official (Requirement 31093).

1.4.5 MDAA. The MDAA shall:

a\. Implement the mishap and close call reporting, investigating, and
recordkeeping requirements for their assigned Mission Directorates for
mishaps and close calls that occur outside the Center's gates, during
in-space flight, or at a program/project contractor site that is not
managed by a Center (Requirement 31086).

b\. Approve via signature all his/her program and project (as defined in
NPR 7120.5) Program/Project Mishap Preparedness and Contingency Plans.
(These plans will be developed by the cognizant Center safety offices,
and will include procedures to notify, report, investigate, and record
mishaps and close calls that involve Mission Directorate
programs/projects/activities whether onsite or offsite, and whether on
the ground or in flight.) (Requirement 31088).

> *Note: All mishaps that occur at a Center are investigated per the
> Center's Mishap Preparedness and Contingency Plan. The program's plan
> supports the Center plan by providing additional information such as,
> but not limited to, hazardous materials, partner agreements, and
> program contact lists. It also serves as a stand-alone plan for
> mishaps and close calls that occur outside the Center's gates, during
> in-space flight, or at a program/project contractor site.*

c\. Determine the mishap classification level (or assign a designee to
determine the classification level) for all mishaps for which he/she has
reporting responsibility and obtain concurrence on this classification
level from the Chief/OSMA for Type A and B mishaps, high-visibility
mishaps, and high-visibility close calls (Requirement).

> *Note: Aircraft Operations are managed by a program-independent flight
> operations office; therefore, the Center Director serves as the
> appointing official for Type A mishaps, Type B mishaps,
> high-visibility mishaps, and high-visibility close calls involving
> aircraft managed by his/her Center.*

d\. Serve as the appointing official for Type A mishaps, Type B mishaps,
high-visibility mishaps, and high-visibility close calls that involve
Mission Directorate managed programs/projects/activities that occur
during space flight or occur outside the Center's gates at MDAA
program/project sites (excludes off-site Center support contractor
locations).

> *Aircraft Operations are managed by a program-independent flight
> operations office; therefore, the Center Director serves as the
> appointing official for mishaps and close calls involving aircraft
> managed by his/her Center.*

e\. Serve as the appointing official (or designate the responsibility in
the Program/Project Mishap Preparedness and Contingency Plan) for Type C
mishaps, Type D mishaps, and close calls that involve Mission
Directorate managed programs/project/activities that occur during space
flight or occur outside the Center's gates, during at MDAA
program/project sites (excludes off-site Center support contractor
locations).

f\. Provide funding and support for investigations within their programs
and involving their hardware, facilities, or enabling activities
(Requirement 31094).

g\. Ensure that agreements for joint programs with international
partners and other Federal agencies incorporate elements of this NPR to
ensure that joint mishap investigating and reporting complies with NASA
requirements (Requirement 17020).

1.4.6 Assistant Administrator, Office of Public Affairs (AA/OPA).

a\. The AA/OPA shall establish guidelines for the public release of
mishap reports and related information (Requirement 31096).

b\. With the assistance of the Center safety office, Interim Response
Team (IRT), investigating authority, and CD or AA/OIA, the AA/OPA shall
release information to the press and media (i.e., potential hazards that
may affect the public, interim reports, and the authorized mishap
report) (Requirement 31097).

c\. For Type A mishaps, Type B mishaps, high-visibility mishaps, and
high-visibility close calls, the AA/OPA (or designee) shall appoint a
Headquarters public affairs advisor (Requirement 31098). (For Type B
mishaps the AA/OPA may delegate authority to appoint a public affairs
advisor to the Center Public Affairs Office \[PAO\].)

1.4.7 CD and AA/OIA. The CD and the AA/OIA shall:

a\. Develop Center and Program Mishap Preparedness and Contingency Plans
to support this NPR (this includes procedures to notify, report,
investigate, and record mishaps and close calls that involve programs,
projects, and activities that fall under their responsibility)
(Requirement).

b\. Implement the mishap reporting, investigating, and recordkeeping
requirements for all projects, programs, and activities that fall under
their SMA responsibility (Requirement).

c\. Provide funding and support for investigations at their Centers,
within their projects and programs, and involving their hardware,
facilities, or enabling activities (Requirement).

d\. Determine the mishap classification level (or assign a designee to
determine the classification level) for all mishaps for which the Center
has reporting responsibility and obtain concurrence on this
classification level from the Chief/OSMA for Type A and B mishaps,
high-visibility mishaps, and high-visibility close calls (Requirement
31101).

e\. Serve as the appointing official for Type A mishaps, Type B mishaps,
high-visibility mishaps, and high-visibility close calls that occur at
his/her Center, at off-site Center support contractor locations, or at
off-site contractor locations that are managed by the Center and are not
part of any MDAA program/project activity (Requirement).

> *Note: Aircraft Operations are managed by a program-independent flight
> operations office; therefore, the Center Director serves as the
> appointing official for mishaps and close calls involving aircraft
> managed by his/her Center.*

f\. Serve as the appointing official (or designate the responsibility in
the Center Mishap Preparedness and Contingency Plan) for Type C mishaps,
Type D mishaps, and close calls that occur at his/her Center, at
off-site Center support contractor locations, or at off-site contractor
locations that are managed by the Center and are not part of any MDAA
program/project activity.

g\. In the event that there is a mishap involving injury of a human
research subject at a NASA Center, request the Chief Health and Medical
Officer (CHMO) concurrence on the investigating authority\'s membership
(Requirement).

h\. 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 (Requirement).

i\. Personally report, by telephone or e-mail, to the Administrator
within 24 hours of any nonoccupational fatality, such as sudden cardiac
arrest of a NASA civil service employee or a resident contractor that
occurred on site (a resident contractor is a NASA contractor whose
primary place of business is on or near a NASA Center or NASA-owned
facility) (Requirement).

j\. Personally report, by telephone or e-mail, to the Administrator when
it becomes known that there is any off-the-job fatality or serious
injury/illness of a NASA civil service employee or resident contractor
(Requirement).

k\. Ensure that local procedures for dealing with the needs of the NASA
workforce (civil service employees and contractor employees) when they
are experiencing a crisis situation (e.g., serious injury, illness, or
fatality of workforce member or family member) are:

\(1\) Reviewed annually (Requirement).

\(2\) Include a process for immediately notifying the next of kin for
mishaps and on site nonoccupational medical events resulting in fatality
or serious injury (Requirement).

\(3\) Provide information to the person or family (when the person is
unable to receive such information due to the injury or illness)
concerning benefits, such as extended sick-leave and disability
(Requirement).

l\. Ensure that the NASA civil service employees designated to
communicate with the family of an injured, ill, or deceased individual
have received training in NASA policy concerning benefits and crisis
intervention (Requirement).

m\. Initiate the use of the NASA Family Assistance Fund (NFAF), upon the
NASA civil service employee family's agreement or request (Requirement).

> *Note: The NFAF, in cooperation with the Federal Employees Education
> and Assistance Fund (FEEA), is available to help meet the unforeseen
> medical, financial, and educational needs of NASA civil service
> employees. NFAF and FEEA do not provide assistance to contractors.
> Upon request from a NASA civil service employee, NASA Human Resources,
> Personnel Division, will contact the Chair of the NFAF and FEEA's
> Washington Representative, to request assistance. FEEA can assist with
> immediate financial needs, such as funeral expenses, medical expenses,
> and short-term financial hardships.*

n\. Obtain concurrence from the Chief/OSMA and the Chief Engineer on the
MIB membership of Type A, Type B, high-visibility mishaps, and
high-visibility close calls in which he/she is the appointing official
(Requirement 31103).

o\. Provide administrative and logistical support for the investigating
authority working on the Center and distribute the authorized mishap
report per this NPR (Requirement 31104).

p\. Verify that NASA contractors and grantees conduct mishap
investigations and provide mishap reports as specified in their
contracts and in NFS 1852.223-70 (Requirement 31105).

q\. Serve as an endorsing official for mishaps and close calls in which
he/she is the appointing official (Requirement 31106).

1.4.7.1 The AA/OIA shall provide funding and support for investigations
of mishaps that occur at NASA Headquarters (Requirement 31107).

1.4.8 Program and Project Managers. Program and project managers shall:

a\. Concur on the Program/Project Mishap Preparedness and Contingency
Plan (Requirement 31109).

b\. In the event of a mishap or close call at the Center, activate the
Program Mishap Preparedness and Contingency Plan (Requirement 31111).

c\. Provide funding and support for investigations within their program
jurisdiction or involving their hardware and facilities (Requirement
31112).

d\. Assist the investigating authority as requested (Requirement 31113).

e\. When tasked by the appointing official, develop the Corrective
Action Plan (CAP), implement the CAP, support the Center safety office
personnel as they verify that the CAP has been completed, and generate
the lessons learned (Requirement 31114).

1.4.9 Responsible Organization. The responsible organization shall:

a\. Assist the investigating authority as requested (Requirement 31116).

b\. When tasked by the appointing official, develop the CAP, implement
the CAP, support the Center safety office personnel as they verify that
the CAP has been completed, and generate the lessons learned
(Requirement 31117).

1.4.10 Appointing Official. The appointing official shall:

a\. Use this NPR to determine the type of investigating authority (i.e.,
Mishap Investigation Board \[MIB\], Mishap Investigation Team \[MIT\],
or Mishap Investigator \[MI\]) that will investigate a mishap or close
call or, alternately, whether NASA will accept the investigation and
subsequent mishap report of another competent authority that may have
jurisdiction (Requirement 31119).

b\. Determine the level of NASA involvement, if any, when a mishap
resulted from the actions of an outside source that was not involved in
NASA operations (Requirement 31120).

c\. Initiate a NASA investigation pursuant to this NPR, when the
appointing official believes that a NASA contractor\'s/grantee\'s mishap
report is not adequate because it failed to reach root cause(s), failed
to provide recommendations that prevent recurrence, is not suitably
independent, or is in some other way deficient (Requirement 31121).

d\. Generate a formal memorandum for Type A mishaps, Type B mishaps,
high-visibility mishaps, and high-visibility close calls that
communicates the appointment of the investigating authority members, the
chairperson, the ex officio, and the advisors (Requirement 31122). (For
Type C mishaps, Type D mishaps, and close calls, the appointment orders
can be less formal and communicated via a Center process.)

e\. Serve as an endorsing official for mishaps and close calls in which
he/she is the appointing official (Requirement 31123).

f\. Assign the responsible organization(s)/program(s)/project(s) to
develop the CAP, implement the CAP, and generate the lessons learned
(Requirement 31124).

g\. Ensure that the mishap investigation process for the assigned mishap
or close call is properly completed (Requirement 31125).

h\. Verify that the mishap report is reviewed, endorsed, and authorized
for public release (Requirement 31126).

i\. Ensure that the CAP is developed and implemented (Requirement
31127).

j\. Ensure that the lessons learned are developed, reviewed, and
authorized for public release (Requirement 31128).

k\. Release the investigating authority from duty (Requirement 31129).

l\. Generate the CAP closure statement and the mishap activities
completion statement (Requirement 31130).

m\. Assist the investigating authority as requested (Requirement 31134).

n\. If the NTSB performs an investigation, the appointing official
shall:

\(1\) Initiate a NASA mishap investigation per this NPR (Requirement
31132).

\(2\) Request that a NASA representative be a party to the NTSB\'s
investigation (Requirement 31133).

1.4.11 Endorsing Official.

a\. The endorsing official shall review the mishap investigation report
and provide a signed written endorsement, comments, and a recommendation
as to whether the mishap report should be approved or rejected
(Requirement 31135).

b\. This endorsement and any comments shall be attached to the mishap
report and become part of the permanent record (Requirement 31136).

1.4.12 Ex Officio. The ex officio shall:

a\. Serve as the authorized representative of the Chief/OSMA
(Requirement 31138).

b\. Be a nonvoting participant in all investigation deliberations
(Requirement 31139).

c\. Participate in all investigation proceedings as he/she deems
appropriate (Requirement 31140).

d\. Assure that the investigation is conducted in conformance with NASA
policy and this NPR and the investigation process is fair, independent,
and nonpunitive (Requirement 31141).

e\. Assure that the mishap report contains the proper elements including
proximate cause(s), root cause(s), failed barrier(s), and
observation(s); sufficient facts/data to support the finding(s) and
recommendation(s); and a mishap investigation summary (Requirement
31142).

f\. Sign the final mishap report demonstrating his/her belief that
paragraphs 1.4.12.d-1.4.12.e, and paragraphs 1.7.1.a-1.7.1.l of this NPR
have been satisfied or attach a signed written description of the
report\'s deficiencies (Requirement 31143).

g\. For Type A mishaps, Type B mishaps, high-visibility mishaps, and
high-visibility close calls, provide the Chief/OSMA interim briefings on
the status of the investigation, upon his/her request (Requirement
31144).

1.4.13 Chairperson. The chairperson of the investigating authority
shall:

a\. Manage and coordinate all aspects of the mishap investigation,
including, but not limited to, the following tasks: assign group
leaders; interview witnesses; reconstruct the mishap or close call;
identify facts; identify proximate cause(s) and root cause(s); generate
recommendation(s); and complete the mishap report (Requirement 31146).

b\. Have the authority to impound data, records, equipment, and
facilities and collect/salvage data and debris.

c\. For mishaps at contractor or subcontractor sites, work through the
contracting officer with guidance from the legal advisor to obtain and
impound data.

> *Note: For mishaps outside the Center's gates, NASA has the authority
> to impound NASA property, however, the ability to impound or collect
> other data, records, and equipment is determined by the local and
> Federal laws, Agency agreements, and contracts.*

d\. Release impounded data, records, equipment, facilities, and the
mishap site when they are no longer needed by the investigating
authority.

> *Note: If repairs or modifications need to be made prior to returning
> equipment or facilities to use, the release of impounded items should
> include a letter stating what action(s) is (are) needed.*

e\. Define the roles and/or areas of investigative responsibility for
each group or subgroup on the MIB or MIT, as needed (Requirement 31147).

f\. Coordinate with the investigating authority\'s legal advisor,
Headquarters or Center public affairs advisor, and import/export control
advisor throughout the investigation (Requirement 31148).

g\. Report only to the appointing official (or designee) during the
investigation (Requirement 31149).

> *Note: The intent of this requirement is to provide the Chair of the
> Investigating Authority with only one supervisor during the
> investigation, thereby preventing numerous NASA requests for data and
> status. The report to the appointing official may include information
> such as a status, facts, preliminary findings (if the Chair desires),
> and recommendations which need immediate implementation.*

h\. Refer allegations and evidence of criminal activity that are
identified in the course of an investigation to the Office of Inspector
General (Requirement 31150). Privileged witness statements will be
protected to the extent provided by law.

1.4.14 Investigating Authority. The investigating authority shall
conduct a comprehensive investigation within the defined scope of the
appointment letter or appointment orders, generate the products
indicated in paragraph 1.7 and Figure 5 of this NPR, prepare a mishap
report, and sign the report (Requirement 31151).

1.4.15 Investigating Authority\'s Advisors. The advisors shall:

a\. Attend meetings as needed, travel with the investigating authority
as requested, and have access to all investigative material with the
exception of witness statements and testimony (Requirement 31153).

> *Note: The legal advisor may review witness statements and testimony
> in order to provide adequate legal guidance.*

b\. Provide advice to the investigating authority (Requirement 31154).

c\. Sign the mishap report stating that he/she has reviewed the mishap
report and that it meets NASA policies and procedures in his/her
functional area. (Requirement 31155).

1.4.16 Legal Advisor. The legal advisor shall:

a\. Develop nondisclosure agreements if the investigating authority uses
a contractor as administrative support (Requirement).

b\. Develop nondisclosure agreements if the investigating authority uses
a contractor to analyze interview data or participate in interviews
(Requirement).

c\. Provide legal advice and counsel as requested by the board chair
(Requirement).

d\. Attend interviews, if the interviewee is accompanied by a lawyer
during the interview process.

1.4.17 The advisors may be included or excluded from listening to any
deliberations at the discretion of the chairperson.

1.4.17.1 The chairperson may exclude advisors (with the exception of the
legal advisor) from participating in deliberations that discuss
privileged witness testimony (Requirement).

> *Note: The legal advisor may review witness statements and testimony
> in order to provide adequate legal guidance.*

1.4.18 Investigating Authority\'s Consultants. Per their contract,
consultants shall:

a\. Provide advice to the investigating authority.

b\. Perform analysis.

c\. Assist in formulating conclusions, as requested.

1.4.19 The consultants shall not:

a\. Participate in deliberations (vote on findings) (Requirement 31161).

b\. Sign the mishap report (Requirement 31162).

c\. Read, listen to, or participate in witness interviews unless they
are tasked to analyze interviews, and they have signed a nondisclosure
agreement prepared by NASA Office of the General Counsel or Center Chief
Counsel (Requirement 31163).

> *Note: Contractors specializing in witness interview techniques or
> technical expertise may be hired by the MIB, if the following are
> true: the contractor hired to support the MIB:*
>
> *a. is not affiliated with the mishap, the contractors, or responsible
> organizations involved in the mishap;*
>
> *b. is specifically tasked by contract to support the interview
> process or analyze interviews;*
>
> *c. has signed the nondisclosure agreement prior to their
> participation or support; and*
>
> *d. NASA does not have a sufficient number of Federal employees or
> expertise on the board to perform the task.*

1.4.20 If the Chair of the Investigating Authority chooses to use a
person that is not a Federal employee as administrative support, that
person shall sign a nondisclosure agreement prior to having access to
any mishap data or International Traffic Arms Regulations (ITAR), Export
Administration Regulations (EAR), proprietary, or privileged information
(Requirement).

> *Note: An administrative support person may support the mishap board.
> This support may include access to privileged interview statements as
> long as the person is a Federal employee or the person has signed the
> appropriate nondisclosure agreement prior to having access to any
> mishap data or information.*

1.4.21 Interim Response Team (IRT). The IRT shall:

a\. Notify the Center PAO about casualties, damages, and any potential
hazards to the public, and notify legal advisors (as appropriate)
(Requirement 31168).

b\. Assist the incident commander, as requested (Requirement 31169).

c\. Preserve evidence, document the scene, identify witnesses, and
collect debris.

d\. Only Federal employees on the IRT shall support the Center safety
office in impounding data and collecting witness statements (written
statements when possible) (Requirement 31170).

e\. For mishaps at contractor or subcontractor sites, the IRT shall work
through the contracting officer, with the guidance from the legal
advisor, to obtain and impound data.

> *Note: For mishaps outside the Center's gates, NASA has the authority
> to impound NASA property, however, the ability to impound or collect
> other data, records, and equipment is determined by the local and
> Federal laws, Agency agreements, and contracts.*

f\. Advise the supervisor if drug testing should be requested per the
NPR 3792.1, Plan for a Drug-Free Workplace (Requirement 31171).

> *Note: Per NPR 3792.1 the supervisor shall initiate drug testing after
> a mishap if the mishap results in a fatality or personal injury
> requiring immediate hospitalization or in damage estimated to be in
> excess of \$10,000 to government or private property. This applies to
> Federal employees only. Drug testing of contractors is dependent upon
> their contract.*

g\. Provide all available mishap data and evidence to the investigating
authority (Requirement 31172).

h\. Support the AA/OPA (or designee), Center safety office, IRT, and CD
or AA/OIA in the release of information to the press and media to alert
Center personnel and the public of any known hazards and their potential
effects, and provide instructions that will mitigate the risk and harm
(Requirement).

1.4.22 Incident Commander. The incident commander shall implement the
procedures outlined in the Center Mishap Preparedness and Contingency
Plan to coordinate rescue activities, mitigate hazards, and safe and
secure the mishap site (Requirement 31173).

1.4.23 Center Safety Office. The Center safety office shall:

a\. Support the development of the Center Mishap Preparedness and
Contingency Plan, Program Mishap Preparedness and Contingency Plan(s),
contract clauses, mishap investigation training, and a mishap
investigation tool repository (that makes tools readily accessible to
investigating authorities) (Requirement 31175).

b\. Develop the Program/Project Mishap Preparedness and Contingency
Plans for Programs/Projects as defined by NPR 7120.5 and that their
Center manages. Programs with aircraft in the developmental,
qualification, or certification phases of the program shall have a
Program Mishap Preparedness and Contingency Plan that is tailored for
the particular phase of the program. (Requirement 31110).

c\. Ensure that their Center\'s employees are familiar with the roles
and responsibilities as documented within the Center Mishap Preparedness
and Contingency Plan and this NPR (Requirement 31176).

d\. Implement the Center Mishap Preparedness and Contingency Plan; when
applicable, support the program as they initiate the Program Mishap
Preparedness and Contingency Plan; and initiate, facilitate, and
coordinate all investigation activities per the plan (Requirement
31177).

e\. Report the mishap to Headquarters per the reporting requirements
defined in this NPR and to OSHA (when applicable) (Requirement 31178).

f\. Support the incident commander as he/she safes and secures the
mishap site (Requirement 31179).

g\. Impound data, records, equipment, and facilities (Requirement
31180).

h\. Advise the supervisor that drug testing should be initiated
(Requirement 31181).

i\. Collect witness statements (written statements preferred)
(Requirement 31182).

j\. Ensure that mishap and close call information is entered in the
Incident Reporting Information System (IRIS) per the requirements
outline in this NPR (Requirement 31183).

> *Note: Close calls involving aircraft may be entered into the NASA
> Aviation Anomaly Reporting System (NAARS) in lieu of IRIS.*

k\. Verify the CAP is complete and all elements of the investigation
have been completed (Requirement 31184).

l\. Retain mishap investigation records per NPR 1441.1 and physical
evidence (debris) as necessary (Requirement 31185).

m\. Keep an updated list of all Center personnel that have training and
experience in mishap investigation including information such as
relevant training courses, date of training, recent participation in a
mishap investigation, and security clearances (Requirement 31186).

n\. Establish a Center-specific process to disseminate to other Centers
the final mishap report and to rapidly disseminate preliminary mishap
and close call precautionary information that meets the PAO guidelines
for release (Requirement 17028).

1.4.24 The Office of Security and Program Protection (OSPP) shall:

a\. Upon request from the appointing official, perform a classification
review of the endorsed mishap report to determine if any section of the
report (or the whole report) needs to be classified or if it may be
authorized for public release.

1.4.25 The Center security office shall:

a\. Support the Incident Commander, Center safety office, and IRT in
securing the mishap site and impounding data, records, equipment, and
facilities (Requirement 31187).

1.4.26 Supervisors. Supervisors shall:

a\. Notify the Center safety office when a mishap or close call occurs
(Requirement 31189).

b\. Support the incident commander as he/she secures and safes the
mishap site (Requirement 31190).

c\. Initiate drug testing after a mishap if the mishap results in a
fatality or personal injury requiring immediate hospitalization or in
damage estimated to be in excess of \$10,000 to government or private
property (Requirement 31191).

d\. Assist the investigating authority, as requested (Requirement
31192).

e\. Complete the initial mishap or close call report in accordance with
the Center Mishap Preparedness and Contingency Plan (Requirement 31193).

1.4.27 All Employees. All employees shall:

a\. If witness to, or involved in, a NASA mishap or close call,
immediately notify both emergency response (e.g., 911, fire, ambulance,
Center security office) of the need for assistance and a supervisor,
management official, or a safety/health staff member of the circumstance
of the mishap or close call (Requirement 31195).

b\. Complete witness statements prior to leaving the mishap
investigation site, to the extent possible (Requirement 31196).

c\. Provide as much information as possible to the investigating
authority (Requirement 31197).

1.4.28 Center\'s Chief of Aircraft Operations. The Chief of Aircraft
Operations shall notify the NTSB of a mishap involving aircraft per
paragraph 1.6.6 of this NPR and complete NTSB Form 6120 per paragraph
1.6.8 of this NPR and NTSB requirements (Requirement 31198).

1.4.29 Contracting Officers. Contracting officers shall:

a\. Involve the Center safety office in the acquisition strategy
planning activities for proposed contracts as detailed in NASA NFS Part
1807, \"Acquisition Planning\" (Requirement 31200).

b\. Incorporate applicable mishap and close call reporting and
investigating procedures and corrective action requirements detailed in
the NFS into contracts and grants covering NASA programs and operations
(Requirement 31201).

c\. Coordinate with the contractor and subcontractor sites to assist the
investigating authority in gaining contractor site access, impound
contractor data, and interview contractor personnel as permitted by the
contract (Requirement).

1.4.30 CHMO. The CHMO shall:

a\. Serve as the appointing official for a mishap involving a human
research subject participating in NASA-funded research at a grantee
site, or at another offsite location, and obtain the concurrence from
the Chief/OSMA on the investigating authority's membership
(Requirement). In these investigations, the investigating authority
composition shall include a safety officer that is trained in mishap
investigation (Requirement).

> *Note: If the mishap involving a human research subject occurs at a
> Center, the Center Director will serve as the appointing official per
> this NPR. For mishaps involving a human research subject the
> endorsement and authorization for public release processes will remain
> the same.*

b\. Serve as an endorsing official for Type A mishaps, Type B mishaps,
high-visibility mishaps, and high-visibility close calls involving an
injury or fatality (Requirement 31202).

1.4.31 Office of Institutions and Management, Office of Infrastructure
and Administration, Aircraft Management Division (AMD). For Type A
mishaps, Type B mishaps, high-visibility mishaps, and high-visibility
close calls involving aircraft AMD shall serve as an endorsing official
(Requirement 31203).

1.4.32 Office of the General Counsel. The Office of the General Counsel
shall:

a\. Develop and implement procedures for collateral investigations that
will be performed for mishaps and close calls that do not involve
criminal activity (Requirement 31205).

b\. Assist the AA/OPA (or designee) in the review of the approved mishap
report as it is being prepared for public release (Requirement 31206).

1.4.33 Chief Engineer. The NASA Chief Engineer shall:

a\. Concur on MIB membership for Type A mishaps, Type B mishaps,
high-visibility mishaps, and high-visibility close calls (Requirement).

b\. Serve as an endorsing official for Type A mishaps, Type B mishaps,
high-visibility mishaps, and high-visibility close calls (Requirement).

1.4.34 Roles and responsibilities are summarized in Figure 2.

> Figure 2. Mishap Organizational Responsibilities Matrix

![](media/image2.wmf){width="7.147916666666666in"
height="8.478472222222223in"}

**1.5 Notification and Reporting Requirements**

1.5.1 Immediately after a mishap or close call, NASA employees shall
notify the appropriate authorities in the manner specified in paragraph
1.4.27 of this NPR and the Center Mishap Preparedness and Contingency
Plan (Requirement 31209).

1.5.2 The Center safety office shall collect employee safety concerns,
mishap reports, and close call reports through a Center process, review
the employee reports, verify that they meet the definitions of mishap or
close call found in Appendix A and Figure 1, and report those that are
consistent with the NPR (Requirement 31210).

1.5.3 Notify Office of Safety and Mission Assurance, Safety and
Assurance Requirements Division (OSMA/SARD). After emergency response
has been initiated, within one hour of the occurrence of a Type A
mishap, Type B mishap, high-visibility mishap, or high-visibility close
call, the Center safety office shall notify OSMA/SARD by calling
1.202.358.0006, or, if no answer, by calling the NASA Headquarters After
Hours Contact Center at 1.866.230.6272 (Requirement 31211).

a\. Mishap notification must be acknowledged (verbally, e-mailed, or
faxed) to meet the intent of this requirement (Requirement 31212).

b\. Per NPR 7100.1, paragraph 11.4.1, this includes immediately
reporting a human test subject injury or fatality that resulted in a
loss of life, a permanent disability, hospitalization, extensive first
aid, or lost workday\[s\] (Requirement 31213).

1.5.3.1 During this notification, the Center safety office shall provide
the following information: the Center name, location of incident, time
of incident, number of fatalities (if known), number of hospitalized
employees (if known), type of injury (if known), type of damage (if
known), contact person, contact person\'s phone number, and a brief
description of the mishap (Requirement 31214).

1.5.4 Notify OSHA. Within 8 hours of a work-related mishap involving
death of a Federal employee, or the hospitalization for inpatient care
of three or more employees (provided at least one is a Federal
employee), the Center safety office shall notify OSHA by calling the
area office nearest the site of the mishap or OSHA\'s toll-free number,
1.800.321.6742 (Requirement 31216).

1.5.4.1 OSHA notification is required for any fatality or three or more
hospitalizations that occur up to 30 workdays after the respective
mishap (Requirement 31217).

1.5.4.2 The Center safety office shall persist in making contact with
OSHA to provide this report until OSHA has acknowledged receipt of the
report (Requirement 31218).

1.5.4.3 In notifying OSHA, the Center safety office shall provide OSHA
with the following information: the establishment name, location of
incident, time of incident, number of fatalities (if known), number of
hospitalized employees (if known), contact person, contact person\'s
phone number, and a brief description of the mishap (Requirement 31219).

1.5.4.4 After notifying OSHA, the Center safety office shall inform
OSMA/SARD that an oral report has been provided to OSHA (Requirement
31220).

1.5.5 Within 24 hours of a Type A mishap, Type B mishap, high-visibility
mishap, or high‑visibility close call, the Center safety office shall
follow up the initial phone notification by sending an electronic
notification to OSMA/SARD that includes the following information:
Center submitting report; author of report; author\'s phone number and
mail code; date report submitted; time report submitted; incident date;
incident time; incident general location; exact location (if known);
responsible organization; organization\'s point of contact; point of
contact\'s phone number and mail code; mission affected; program impact
(if known); number and type of injuries or fatalities (if known); type
of damage to equipment, flight hardware, flight software, or facilities;
estimate of direct cost of damage; and a brief description of the mishap
or close call (Requirement 31215).

1.5.6 Report Criminal Activity Associated with NASA Mishaps to the
Office of Inspector General (OIG) and to either the Office of the
General Counsel or Center Chief Counsel.

1.5.6.1 The OIG and the Center\'s Office of the Chief Counsel or the
NASA Office of the General Counsel shall be notified if it is suspected
that a mishap resulted from criminal activity (Requirement 31222).

1.5.6.2 Any facts related to criminal activity in connection with a
mishap shall be referred to the OIG (Requirement 31223). Privileged
witness statements will be protected to the extent provided by law.

**1.6 Additional Notification and Reporting Requirements for Aircraft
Investigations**

1.6.1 NASA employees shall report immediately to the Center safety
office any of the aircraft mishaps or anomalies described in Figure 3,
paragraph 1.2, and paragraph 1.6.2 of this NPR (Requirement 31225).

######### Figure 3. NTSB Reportable Events (Per 49 CFR Part 830).

+-----------------------------------------------------------------------+
| **All Aircraft**                                                      |
+-----------------------------------------------------------------------+
| -   Flight control system malfunction or failure.                     |
+-----------------------------------------------------------------------+
| -   All aircraft accidents with substantial damage.                   |
+-----------------------------------------------------------------------+
| -   Inability of any required flight crewmember to perform normal     |
|     flight duties as a result of injury or illness.                   |
+-----------------------------------------------------------------------+
| -   Failure of structural components of a turbine engine, excluding   |
|     compressor and turbine blades and vanes.                          |
+-----------------------------------------------------------------------+
| -   In-flight fire.                                                   |
+-----------------------------------------------------------------------+
| -   Aircraft collision in flight.                                     |
+-----------------------------------------------------------------------+
| -   Damage to property other than the Agency aircraft.                |
+-----------------------------------------------------------------------+
| > For large multiengine aircraft (more than 12,500 pounds maximum     |
| > certificated take-off weight)                                       |
+-----------------------------------------------------------------------+
| -   In-flight failure of hydraulic systems that results in sustained  |
|     reliance on the sole remaining hydraulic or mechanical system for |
|     movement of flight control surfaces.                              |
+-----------------------------------------------------------------------+
| -   Sustained loss of the power or thrust produced by two or more     |
|     engines.                                                          |
+-----------------------------------------------------------------------+
| -   An evacuation of an aircraft in which an emergency egress system  |
|     is used.                                                          |
+-----------------------------------------------------------------------+
| -   An aircraft is overdue and is believed to have been involved in a |
|     mishap or close call.                                             |
+-----------------------------------------------------------------------+

Figure 4: Information Required for All Agency Aircraft Mishaps and Close
Calls

+-----------------------------------------------------------------------+
| 1.  Type, nationality, and registration marks of the aircraft.        |
+-----------------------------------------------------------------------+
| 2.  Name of owner and operator of the aircraft.                       |
+-----------------------------------------------------------------------+
| 3.  Name of the pilot in command.                                     |
+-----------------------------------------------------------------------+
| 4.  Date and time of the mishap, malfunction, or failure.             |
+-----------------------------------------------------------------------+
| 5.  Last point of departure and point of intended landing of the      |
|     aircraft.                                                         |
+-----------------------------------------------------------------------+
| 6.  Position of the aircraft with reference to some easily defined    |
|     geographical point.                                               |
+-----------------------------------------------------------------------+
| 7.  Number of persons aboard and number killed or seriously injured.  |
+-----------------------------------------------------------------------+
| 8.  Nature of the mishap or occurrence, the weather, and the extent   |
|     of damage to the                                                  |
|                                                                       |
| aircraft, so far as is known.                                         |
+-----------------------------------------------------------------------+
| 9.  A description of any explosives, radioactive materials, or other  |
|     dangerous articles carried.                                       |
+-----------------------------------------------------------------------+

1.6.2 Employees shall report unexpected aircraft departure from
controlled flight for all aircraft except the following high performance
jet/test aircraft which can experience departure from controlled flight
when engaged in flight test activities: F-15, F-16, F/A-18, T-38, OV-10,
and T-34 (Requirement 31228). These aircraft are exempt because it is a
common occurrence for a high performance jet/test aircraft that does
dynamic maneuvering to depart from controlled flight.

1.6.3 Immediately after the occurrence of an aviation mishap or
NTSB-defined mishap or close call, the Center aircraft operator shall
provide all the information listed in Figure 4 to the Center safety
office and the Center Chief of Aircraft Operations (Requirement 31229).

1.6.4 The Center safety office shall notify OSMA/SARD and AMD of any
aircraft mishap or close call as listed in paragraph 1.6.2 and Figure 3
of this NPR.

> *Note: Figure 3 and paragraph 1.6.2 are NTSB reporting requirements.
> Consequently, this requirement is in addition to reporting all
> aircraft-related Type A mishaps, Type B mishaps, high-visibility
> mishaps, and high-visibility close calls to the OSMA/SARD.*

1.6.5 The Center safety office shall ensure that for aircraft mishaps
and close calls all information listed in Figure 4 of this NPR (with the
exception of the pilot's name) is entered in IRIS.

> *Note: Close calls involving aircraft may be entered into the NAARS in
> lieu of IRIS.*

1.6.6 The Center's Chief of Aircraft Operations or his/her designee
shall immediately notify the NTSB of any aircraft mishap, incident, or
close call listed in Figure 3 and paragraph 1.6.2 of this NPR and in
accordance with 49 CFR Part 830 and notify OSMA/SARD that NTSB
notification has been completed.

1.6.7 In the event that the NTSB exercises its authority to investigate
a NASA aircraft mishap, NASA shall conduct a separate investigation in
accordance with this NPR (Requirement 31232).

1.6.8 Within 10 workdays of an aircraft mishap or close call that meets
the reporting requirements as defined in Figure 3 and paragraph 1.6.2 of
this NPR, the Center Chief of Aircraft Operations shall submit an NTSB
Form 6120 to the NTSB regional office nearest to the location of the
mishap or close call (Requirement 31233).

1.6.9 An unmanned aerial vehicle (UAV) is not currently considered an
aircraft by the NTSB, consequently NTSB reporting requirements are not
applicable to a UAV unless personnel are injured or the UAV comes down
in a populated area outside a Center\'s gates.

**1.7 Investigation Products for each Classification Level/Type of
Investigation**

1.7.1 The investigating authority shall conduct an investigation and
include the following products in the mishap report according to the
requirements listed in Figure 5:

a\. Investigating authority and ex officio signatures demonstrating
their approval of the mishap report (Requirement 31237).

b\. Advisor(s) signatures demonstrating that he/she has reviewed the
mishap report; that it meets NASA policies and procedures in his/her
functional area; that any privileged or proprietary information, ITAR
information, EAR information, or material subject to the Privacy Act has
been identified and marked as nonreleasable to the public; and that
sections that are releasable to the public are marked releasable and, to
the best of his/her knowledge, are ready for public release (pending
endorsements and Headquarters and Center public affairs authorization)
(Requirement 31238).

c\. List of the investigating authority\'s consultants (Requirement
31239).

d\. An executive summary that does not contain privileged or proprietary
information, material subject to the Privacy Act, ITAR information, or
EAR information (Requirement 31240).

e\. The OSHA Final Mishap Summary (OSHA 301 Form: Injury and Illness
Incident Report, or an equivalent form), if the mishap is an OSHA
recordable incident (Requirement 31241).

f\. Description of the type of data gathered and evaluated during the
investigation (Requirement 31242).

g\. Narrative description of the facts including what, when, and where
(Requirement 31243).

h\. Timeline (Requirement 31244).

i\. Description of all structured analysis techniques used and how they
contributed to determining the findings (Requirement 31245).

j\. Event and causal factor tree or similar graphical representation of
the mishap (Requirement 31246).

k\. Description explaining why the mishap/close call occurred including
all finding(s) such as proximate cause(s), root cause(s), contributing
factor(s), failed barrier(s), observation(s), and the evidence upon
which the findings are based (Requirement 31247).

l\. Conclusions and recommendations (Requirement 31248).

m\. Minority report, if there is one (Requirement 31249).

Figure 5. Classification Level/Investigation Type with Corresponding
Appointing Official, Endorsing Officials, and Required Products in the
Mishap Report

+---------+---------+-----------+---------+--------+--------+--------+
|         | Classif |           |         |        |        |        |
|         | ication |           |         |        |        |        |
|         | Level & |           |         |        |        |        |
|         | Invest  |           |         |        |        |        |
|         | igation |           |         |        |        |        |
|         | Type    |           |         |        |        |        |
+---------+---------+-----------+---------+--------+--------+--------+
|         | H       | Type A    | Type B  | Type C | Type D | Close  |
|         | igh-Vis |           |         |        |        | Call   |
|         | ibility |           |         |        |        |        |
|         |         |           |         |        |        |        |
|         | Mishap  |           |         |        |        |        |
|         | or      |           |         |        |        |        |
|         |         |           |         |        |        |        |
|         | Close   |           |         |        |        |        |
|         | Call    |           |         |        |        |        |
+---------+---------+-----------+---------+--------+--------+--------+
| Invest  | MIB^1^  | MIB       | MIB     | MIT or | MIT or | MIT or |
| igating |         |           |         | MI     | MI     | MI     |
| Au      |         | (at least | (at     |        |        |        |
| thority |         | 5         | least 3 |        |        |        |
|         |         | members)  | m       |        |        |        |
|         |         |           | embers) |        |        |        |
+---------+---------+-----------+---------+--------+--------+--------+
| R       | All     | All (a-m) | All     | a-e,   | a, b,  | a, b,  |
| equired | (a-m)   |           | (a-m)   | g, l,  | g, k,  | g, k,  |
| P       | ^1^     |           |         | k ,m   | l, m   | l, m   |
| roducts |         |           |         |        |        |        |
+---------+---------+-----------+---------+--------+--------+--------+
| App     | MDAA    | Adminis   | CD or   | CD     | CD     | CD     |
| ointing |         | trator^2^ | AA/OIA  | de     | de     | de     |
| O       | (For    |           |         | signee | signee | signee |
| fficial | O       | AA^2^,    | (For    | or     | or     | or     |
|         | ffsite, |           | Center  | AA/OIA | AA/OIA | AA/OIA |
|         | In      | or        | Onsite  | de     | de     | de     |
|         | -flight |           | or      | signee | signee | signee |
|         | or      | CD or     | Offsite |        |        |        |
|         | Program | AA/OIA    | Center  | (For   | (For   | (For   |
|         | Con     |           | Support | Center | Center | Center |
|         | tractor | (For      | Cont    | Onsite | Onsite | Onsite |
|         | S       | Center    | ractor) | or     | or     | or     |
|         | ite)^1^ | Onsite or |         | O      | O      | O      |
|         |         | Offsite   | or      | ffsite | ffsite | ffsite |
|         | or      | Center    |         | Center | Center | Center |
|         |         | Support   | MDAA    | S      | S      | S      |
|         | CD or   | Co        |         | upport | upport | upport |
|         | AA/OIA  | ntractor) | (For    | Contr  | Contr  | Contr  |
|         |         |           | O       | actor) | actor) | actor) |
|         | (For    | or        | ffsite, |        |        |        |
|         | Center  |           | I       | or     | or     | or     |
|         | Onsite, | MDAA      | n-space |        |        |        |
|         | or      |           | flight  | MDAA   | MDAA   | MDAA   |
|         | Offsite | (For      | or at a | De     | De     | De     |
|         | Center  | Offsite,  | Program | signee | signee | signee |
|         | Support | In-space  | Con     |        |        |        |
|         | Cont    | flight or | tractor | (For   | (For   | (For   |
|         | ractor) | at a      | Site)   | Of     | Of     | Of     |
|         | ^1^     | Program   |         | fsite, | fsite, | fsite, |
|         |         | C         | or      | In     | In     | In     |
|         | or      | ontractor |         | -space | -space | -space |
|         |         | Site)     | CHMO    | flight | flight | flight |
|         | CHMO    |           |         | or at  | or at  | or at  |
|         |         | or        | (For    | a      | a      | a      |
|         | (For    |           | Offsite | P      | P      | P      |
|         | Offsite | CHMO      | Human   | rogram | rogram | rogram |
|         | Human   |           | R       | Cont   | Cont   | Cont   |
|         | R       | (For      | esearch | ractor | ractor | ractor |
|         | esearch | Offsite   | Su      | Site)  | Site)  | Site)  |
|         | Su      | Human     | bjects) |        |        |        |
|         | bjects) | Research  |         | or     | or     | or     |
|         |         | Subjects) |         |        |        |        |
|         |         |           |         | CHMO   | CHMO   | CHMO   |
|         |         |           |         |        |        |        |
|         |         |           |         | (For   | (For   | (For   |
|         |         |           |         | O      | O      | O      |
|         |         |           |         | ffsite | ffsite | ffsite |
|         |         |           |         | Human  | Human  | Human  |
|         |         |           |         | Re     | Re     | Re     |
|         |         |           |         | search | search | search |
|         |         |           |         | Sub    | Sub    | Sub    |
|         |         |           |         | jects) | jects) | jects) |
+---------+---------+-----------+---------+--------+--------+--------+
| Conc    | Chief/  | C         | Chi     | C      | C      | C      |
| urrence | OSMA^1^ | hief/OSMA | ef/OSMA | HMO^7^ | HMO^7^ | HMO^7^ |
| on MIB  |         |           |         |        |        |        |
| Mem     | Chief   | Chief     | Chief   |        |        |        |
| bership | Engi    | Engineer  | E       |        |        |        |
|         | neer^1^ | CHMO^7^   | ngineer |        |        |        |
|         |         |           | CHMO^7^ |        |        |        |
|         | CHMO^7^ |           |         |        |        |        |
+---------+---------+-----------+---------+--------+--------+--------+
| En      | App     | A         | Appr    | Appo   | Appo   | Appo   |
| dorsing | ointing | ppointing | opriate | inting | inting | inting |
|         | Offic   | Official, | MDAA,   | Of     | Of     | Of     |
| Of      | ial^1^, |           |         | ficial | ficial | ficial |
| ficials |         | Admi      | App     | and    | and    | and    |
|         | Chief/O | nistrator | ointing |        |        |        |
|         | SMA^1^, | ^2^,      | Of      | Center | Center | Center |
|         |         |           | ficial, | P      | P      | P      |
|         | Chief   | C         |         | rocess | rocess | rocess |
|         | E       | hief/OSMA | Chi     |        |        |        |
|         | ngineer |           | ef/OSMA |        |        |        |
|         |         | Chief     |         |        |        |        |
|         | AM      | Engineer  | Chief   |        |        |        |
|         | D^1,3^, |           | E       |        |        |        |
|         |         | AMD^3^,   | ngineer |        |        |        |
|         | P       |           |         |        |        |        |
|         | rocurem | CHMO ^4^, | AMD^3^, |        |        |        |
|         | ent^1^, |           |         |        |        |        |
|         |         | Procur    | C       |        |        |        |
|         | CHMO    | ement^5^, | HMO^4^, |        |        |        |
|         | ^1,4^,  |           |         |        |        |        |
|         |         | Other^5^  | P       |        |        |        |
|         | O       |           | rocurem |        |        |        |
|         | ther^1^ |           | ent^5^, |        |        |        |
|         |         |           |         |        |        |        |
|         |         |           | > Other |        |        |        |
+---------+---------+-----------+---------+--------+--------+--------+
| Of      | General | General   | General | Center | Center | Center |
| ficials | Coun    | Counsel,  | C       | Chief  | Chief  | Chief  |
| Re      | sel^1^, |           | ounsel, | Co     | Co     | Co     |
| viewing |         | OPA,      |         | unsel, | unsel, | unsel, |
| Mishap  | OPA^1^, |           | OPA,    |        |        |        |
| Report  |         | NASA      |         | Center | Center | Center |
| Prior   | NASA    | Export    | NASA    | PAO,   | PAO,   | PAO,   |
| to      | Export  | Admin     | Export  |        |        |        |
|         | Adm     | istrator, | Adminis | Center | Center | Center |
| Author  | inistra |           | trator, | Export | Export | Export |
| ization | tor^1^, | OSPP      |         | Ad     | Ad     | Ad     |
| for     |         | (         | OSPP    | minist | minist | minist |
| Public  | OSPP    | Security) | (Se     | rator, | rator, | rator, |
| Release | (Secur  |           | curity) |        |        |        |
|         | ity)^1^ |           |         | Center | Center | Center |
|         |         |           |         | P      | P      | P      |
|         |         |           |         | rocess | rocess | rocess |
+---------+---------+-----------+---------+--------+--------+--------+

1.7.2 For close calls, where the potential for a Type A mishap or Type B
mishap is significant, the Center Safety and Mission Assurance (SMA)
director may consider application of a MIB or MIT investigation and
their associated products. Serious workplace hazards previously
unidentified and discovered as a result of inspections, audits, surveys,
or concerns shall be investigated in the same manner as close calls
(Requirement 31672).

1.7.3 For Type B mishaps, Type C mishaps, Type D mishaps, and close
calls involving a single person, where the injury/illness occurred
because an individual fell down the stairs, slipped or tripped on the
floor or ground, experienced a musculoskeletal disorder (both cumulative
trauma or acute) while performing routine office duties, was bitten by
an insect, and/or aggravated a preexisting medical condition, the mishap
investigation may be performed by one trained mishap investigator
without the support from an ex officio.

> *[Rationale]{.underline}: Brown recluse spider bites result in
> hospitalization. They do not require a full MIB, complex
> investigation, and/or report.*

1.7.4 The CD or AA/OIA shall elevate the level of investigation and
required products of any mishap or close call upon the request of a
higher authority, such as the Administrator, an Associate or Assistant
Administrator, or upon his/her discretion (Requirement 31673).

**1.8 Recording Requirements**

1.8.1 Within 24 hours, the Center safety office shall ensure that all
NASA mishaps and close calls are recorded in IRIS and include the
following information: Center submitting report; author of report;
author\'s phone number and mail code; date report submitted; time report
submitted; incident date; incident time; incident general location;
exact location (if known); responsible organization; organization\'s
point of contact; point of contact\'s phone number and mail code;
mission affected; program impact (if known); number and type of injuries
or fatalities (if known); type of damage to equipment, flight hardware,
flight software, or facilities; estimate of direct cost of damage; and a
brief description of the mishap or close call (Requirement 31252).

> *Note: Close calls involving aircraft may be entered into the NAARS in
> lieu of IRIS.*

1.8.2 For mishaps or close calls involving injury, the occupational
health representative or other medical person shall provide the
appropriate medical information regarding the person(s) injured and the
nature of the injury(s) to the Center safety office for inclusion in
IRIS (Requirement 31253).

1.8.3 The Center safety office shall record mishaps involving injury or
illness to NASA civil service employees on the OSHA 300 Log as required
by 29 CFR Part 1904.7 (Requirement 31254).

1.8.4 The Center safety office shall ensure that the information
recorded in IRIS is updated as new information becomes available and, at
a minimum, verify information is up to date once every 30 days until the
investigation is complete and the corrective actions are complete
(Requirement 31255).

**1.9 Collateral Investigations**

1.9.1 The NASA investigating authority performing the safety
investigation per this NPR shall have primacy over other Agency
collateral investigations, with the exception of OIG criminal
investigations (Requirement 31257).

1.9.2 The investigating authority shall not distribute witness
statements, notes, or transcripts of witness testimony taken during
interviews, or medical records to the collateral investigation board or
any other Agency, unless ordered in a court of law (Requirement 31258).

1.9.3 In an unusual case, the MIB chair shall release privileged witness
testimony and related material to the OIG upon receipt of a written
request that is signed by the Inspector General or Deputy Inspector
General, addressed to the NASA Administrator or Deputy Administrator,
and forwarded to the MIB chair from the Administrator\'s office.

> *Note: The OIG respects and, as a general rule, will defer to the
> disclosure restrictions attendant to NASA mishap investigations. Upon
> receipt of such testimonial information, the OIG will consider it to
> be confidential witness testimony and will treat it as such to the
> full extent required by the Inspector General Act of 1978.*

1.9.4 The investigating authority may provide (at their discretion) the
collateral investigation board with access to factual data, physical
evidence (with the exception of privileged witness statements, notes and
transcripts of privileged testimony, and medical records), analysis, and
any other information that will be contained within the mishap
investigation report authorized for public release.

1.9.5 Members of the investigating authority shall not participate in
both collateral investigations or contractor and safety investigations
for the same mishap or at the same time (Requirement).

**1.10 Investigations by Outside Authorities**

1.10.1 NASA shall support investigations of NASA mishaps by other
Federal agencies authorized to investigate NASA mishaps (Requirement
31261).

[]{.mark}

1.10.2 NASA shall support investigations of mishaps experienced by other
Federal agencies, foreign participants, and private industry in
accordance with agreements (Requirement 31262).

1.10.3 If the NASA appointing official accepts an investigation by other
authorities or contractors that is independent and adequately addresses
proximate cause(s), root cause(s), and contributing factor(s), the
appointing official is not required to conduct a separate NASA
investigation.

1.10.4 Examples of situations where investigations by other parties may
be accepted include the following:

a\. When a Presidential Commission is appointed pursuant to the NASA
Authorization Act of 2005 (Public Law 109-155, Section 821) to
investigate the loss of a Space Shuttle, the loss of ISS or its
operational viability, the loss of any other United States space vehicle
carrying humans that is owned by the Federal Government or that is being
used pursuant to a contract with the Federal Government, or the loss of
a crew member or passenger of any space vehicle described in this
subsection.

b\. Traffic mishaps involving NASA employees in the course of their duty
when investigated by local authorities (i.e., sheriff, state police,
coroners) having jurisdiction.

c\. An injury or fatality where there is substantial reason to believe
the mishap or close call is the result of a criminal or terrorist act to
NASA employees and is investigated by local or Federal law enforcement
authorities such as the Federal Bureau of Investigation; the Bureau of
Alcohol, Tobacco, Firearms, and Explosives; the Department of State; the
Drug Enforcement Agency; the Department of Homeland Security; or the
OIG.

d\. An injury or fatality as a result of a commercial transportation
mishap involving NASA personnel on official business that is
investigated by authorities having jurisdiction, such as the Federal
Aviation Administration and the NTSB.

5.  Contractor and Grantee Mishaps. In those cases that are not NASA
    mishaps (i.e., solely involve a contractor or grantee mishap or
    close call at an offsite location, arising out of work performed
    under a NASA contract and the contractor/grantee is required to
    investigate pursuant to NFS 1852.223-70), the NASA appointing
    official is not required to appoint a separate NASA investigating
    authority unless the contractor\'s/grantee\'s mishap report
    indicates that a NASA policy or procedure was a causal factor or
    contributing factor and a NASA change is warranted.

1.10.5.1 A [contractor onsite injury or illness that is classified as a
Type C mishap, Type D mishap, or Close Call may be investigated by the
contractor per their contract. The mishap report must be delivered to
NASA, and NASA has the option of completing the endorsement
process.]{.underline} (Requirement 31268)

1.10.6 When the onsite incident has been classified as a Type D mishap
or a close call involving government property damage (including flight
hardware, ground processing equipment, and/or the ground facility), the
NASA appointing official may allow contractor investigation of the
mishap per their contract provided the following are true:

a\. NASA serves as the appointing official and approves the
investigating authority.

b\. The investigating authority has the same membership (e.g.,
disciplines and training) as defined in this NPR (NPR 8621.1) with the
exception that all members and advisors are contractor personnel.

c\. The investigating authority performs the investigation per this NPR
with the exception of taking privileged witness statements. (Rationale:
NASA can not protect privileged witness statements taken by a
contractor. Consequently, the contractor is not authorized to grant
privilege.)

d\. The investigating authority produces the products listed in Figure
5.

e\. The NASA appointing official reviews and endorses the report.

**CHAPTER 2. Readiness to Conduct Investigations**

**2.1 Headquarters Operations and Center Mishap Preparedness and
Contingency Plan**

2.1.1 The AA/OIA and each CD shall develop a Center Mishap Preparedness
and Contingency Plan that describes the following:

a\. The local mishap and close call notification, reporting,
investigating, recording, and prevention policies and procedures
(Requirement 31272).

b\. The relationship between the emergency preparedness plan, the Center
Mishap Preparedness and Contingency Plan, and Program Mishap
Preparedness and Contingency Plans and which plan takes precedence given
specific conditions (Requirement 31273).

c\. Management responsibilities for establishing mishap investigations
(Requirement 31274).

d\. Procedures to appoint an IRT for those mishaps and close calls that
are not covered by a program/project Mishap Preparedness and Contingency
Plan (i.e., facility mishaps and close calls) (Requirement 31275).

e\. Procedures to appoint a MIT or MI for Type C mishaps, Type D
mishaps, and close calls that occur at the Center or involve
programs/projects/activities managed by the Center (Requirement 31276).

f\. Roles and responsibilities of the incident commander (or the
location in the emergency preparedness plan where these can be found)
(Requirement 31277).

g\. Procedures to impound appropriate records and equipment that may be
involved in the mishap to prevent unauthorized use or modification
(Requirement 31278).

h\. List of responsible organizations, along with Center safety office
personnel, that shall take immediate action to safeguard (or impound)
appropriate records, equipment, and facilities and secure the mishap
site (Requirement 31279).

i\. Identification of the location or space where impounded data,
records, and equipment shall be stored and secured during an
investigation (Requirement 31280).

j\. Procedures for release of impounded data, records, equipment,
facilities, and the mishap site (Requirement 31281).

k\. Mishap report approval process for Type C mishaps, Type D mishaps,
and close calls that occur at the Center or involve
programs/projects/activities managed by the Center (Requirement 31282).

l\. List of potential contractor support and onsite experts that can
facilitate the immediate acquisition or purchase of products needed by
the investigation board or team (e.g., high resolution cameras,
recording devices, software, and others) (Requirement 31283).

m\. The mandatory schedule for mishap simulations that include
simulation of accident investigation procedures as described in this
NPR, the Center Mishap Preparedness and Contingency Plan, and the
Program Mishap Preparedness and Contingency Plan (Requirement 31284).

n\. The information technology plan to provide computer data retrieval
and data archive support to the investigating authority (Requirement
31286).

o\. Requisite security clearances, if any, for investigating authority
members, chair, and ex officio (Requirement 31287).

p\. Description of the "chain of custody process" that will be used to
secure and safeguard personnel effects and sensitive information related
to injured or deceased individuals (Requirement).

> *Note: This process includes the procedures to provide physical
> security over and controlled access to personal effects and other
> sensitive material.*

q\. The expiration date (Requirement).

> *Note: Depending on the Center personnel turnover and realignments,
> the Center Mishap Preparedness and Contingency Plan, including the
> contact list may need to be updated semiannually or quarterly.*

**2.2 Program and Project Mishap Preparedness and Contingency Plans**

2.2.1 The program/project manager shall concur in a Program/Project
Mishap Preparedness and Contingency Plan that:

a\. Is a comprehensive plan for all mishaps and close calls that occur
offsite, at offsite program/project (as defined by NPR 7120.5)
contractor sites, or in flight.

b\. Is consistent with the Centers\' Mishap Preparedness and Contingency
Plans, for all Centers in which the program operates (Requirement
31290).

c\. Covers any information and procedures required specifically by the
program that are not covered in the Centers\' Mishap Preparedness and
Contingency Plans (i.e., special procedures for safing, handling, or
containing hazardous chemicals present in the program\'s/project\'s
hardware) (Requirement 31291).

d\. Describes the procedures to comply with NPR 8621.1 notification,
reporting, investigating, and recording requirements for all
program/project activities not located at a Center or managed by a
Center (e.g., program/project activities managed by Headquarters and
located at a University, contractor site, or other off-Center location)
(Requirement 31292).

e\. Describes the training requirements and the IRT\'s membership for
mishaps and close calls that occur offsite, at offsite program/project
(as defined by NPR 7120.5) contractor sites, or in flight (Requirement
31293).

f\. Describes any special procedures for the emergency response
personnel, the IRT, and the incident commander that are not covered in
the Center Mishap Preparedness and Contingency Plan or the emergency
response plan (e.g., identification and handling of hazardous
commodities specific to the program) (Requirement 31294).

g\. Describes the procedures to impound data, records, equipment,
facilities, and property not located at a NASA facility (Requirement
31295).

h\. Identifies existing memoranda of agreement with national, state, and
local organizations and agencies that may be utilized during a mishap
investigation (Requirement 31297).

i\. Describes how offsite debris shall be collected, transported, and
stored (Requirement 31298).

j\. Describes the investigation and debris collection process required
for any mishap or close call occurring in a foreign country (Requirement
31299).

k\. Requires that, for NASA-investigated mishaps, NASA personnel shall
perform and control the impounding process (Requirement 31300).

l\. Lists the personnel who will assist in performing the procedures to
impound data, records, equipment, facilities, and other property
(Requirement 31301).

> *Note: Contractor personnel may provide data from their offices and/or
> facilities to the NASA personnel performing this task.*

m\. Identifies the national, state, and local (and, where applicable,
international) organizations and agencies which are most likely to take
part in debris collection; identifies the roles and responsibilities of
each organization; and identifies a point of contact (Requirement
31296).

n\. Addresses the responsibilities and procedures for mishap
investigation in the bilateral or multilateral agreements when the
program involves international partners, program managers, and project
managers (Requirement 31302).

o\. Describes the resources that may be needed from other government
agencies (e.g., Federal Emergency Management Agency, NTSB, DoD,
Department of Justice) during a Type A mishap or Type B mishap
investigation; identifies the point of contact and contact information
for each of these Agencies; describes the procedures to acquire their
assistance; and identifies the potential roles and responsibilities of
each Agency (Requirement 31303).

p\. Includes a list of information such as databases, Web sites,
documentation (including hardware history), drawings, basic system
operation, and procedures that may be scrutinized in a Type A mishap
involving loss of a vehicle and/or major facility damage and frequently
updates this information so that it is easily deliverable to a mishap
investigation board, and includes points of contact for the information.
(Requirement 31304).

q\. Describes the information technology plan to provide computer data
retrieval and data archive support to the investigating authority
(Requirement 31306).

r\. Describes the requisite security clearances, if any, for
investigating authority members, chair, and ex officio participating in
program/project investigations (Requirement 31307).

s\. Describes the "chain of custody process" that will be used to secure
and safeguard personal effects and sensitive information related to
injured or deceased individuals (Requirement).

> *Note: This process includes the procedures to provide physical
> security over and controlled access to personal effects and other
> sensitive material.*

t\. Names of key personnel from the Agency Public Affairs Office and
Office of External Relations (OER) that should be notified for all Type
A and Type B mishaps (Requirement).

u\. States the expiration date (Requirement).

> *Note: Depending on the Program personnel turnover and phase (e.g.,
> test, processing, and flight), the Program/Project Mishap Preparedness
> and Contingency Plan, including the contact list may need to be
> updated semiannually or quarterly.*

2.2.2 The program/project manager shall have the appropriate NASA
Offices, at a minimum, General Counsel, OPA, OER, OSMA, and Centers (all
Centers at which the program/project has activities) review and comment
on the Mishap Preparedness and Contingency Plan prior to its approval
(Requirement 31308).

2.2.3 The program manager (or designee) shall provide the Program Mishap
Preparedness and Contingency Plan to OSMA/SARD for compliance review at
least three weeks prior to the Safety and Mission Success Review (SMSR).

2.2.4 The program manager shall submit the Program Mishap Preparedness
and Contingency Plan to the Chief/OSMA **for concurrence** two weeks
prior to the Program SMSR

2.2.5 The program or project (as defined per NPR 7120.5) Safety and
Mission Assurance representative shall review and approve the Mishap
Preparedness and Contingency Plan, verifying that it has the content
required per this NPR (NPR 8621.1), prior to submittal for signature
(Requirement).

**2.3 Mishap Preparedness and Contingency Plan Practice**

2.3.1 The Program and Center Mishap Preparedness and Contingency Plans,
including emergency response where appropriate, shall be practiced
during contingency simulations that occur prior to a major test, launch,
or space activity (Requirement).

> *Note: Practice is intended to mean tabletop and/or full enactment
> simulations (where possible).*

2.3.2 For ongoing programs with repeated major test, launches, and space
activities, the Program Mishap Preparedness and Contingency Plan,
including emergency response where appropriate, shall be conducted at
least every 18 months.

2.3.3 The Center Safety Office at the Center where the program is
managed shall provide oversight of the Mishap Preparedness and
Contingency Plan simulation.

2.3.4 At the conclusion of the simulation, the Center Safety Office and
Program shall identify any deficiencies in the Mishap Preparedness and
Contingency Plan, update the plan as needed, and/or take other necessary
corrective actions to assure that the plan can be effectively
implemented if a mishap occurs.

**2.4 Contingency Plan Web Site**

2.4.1 All MDAAs, Programs, Projects, and Centers shall submit their
up-to-date Mishap Preparedness and Contingency Plans to OSMA/SARD for
storage on the NASA Process Based Mission Assurance Secure Web Site.

> *Note: The mishap web site provides a secure central repository that
> NASA civil servants can use to find the latest versions of the
> contingency plans.*

**2.5 Contract Clauses**

2.5.1 Contracting officers shall include appropriate mishap and close
call notification, reporting, recording, and investigation procedures in
NASA contracts (Requirement 31310).

2.5.2 The Center safety office shall involve itself in acquisition
strategy meetings per NFS Part 1807, Acquisition Planning, to assure
that the appropriate mishap and close call reporting, investigating, and
evaluation criteria are incorporated into contracts (Requirement 31311).

**2.6 Training**

2.6.1 The Chief/OSMA with the support of the Center safety office shall
provide the necessary training to ensure that at least one member of
each investigating authority and the ex officio has, at a minimum, the
following:

a\. Knowledge of the NASA mishap investigation policy and process as
demonstrated via test (Requirement 31314).

> *Note: The NASA "Introduction to Mishap" course provides the training
> to meet this requirement.*

b\. Knowledge and skills to secure the site; preserve the mishap scene;
interview witnesses; collect and impound data, records, equipment and
facilities; create time lines; document facts; generate fault trees;
perform barrier analysis; perform change analysis; create event and
causal factor trees; obtain forensic analysis; integrate evidence; draw
conclusions; generate recommendations; and generate mishap reports
(Requirement 31315).

2.6.2 The Chief/OSMA, with the support of the Center safety office,
shall provide the necessary training to ensure that the human factors
mishap investigator has the following:

a\. At a minimum, knowledge (as demonstrated via test or on-the-job
training) of the method to identify unsafe acts and errors, identify
types of errors, identify causal and contributing factors for errors,
identify performance shaping factors, interview witnesses, analyze data,
create timelines, perform fault tree analysis, perform barrier analysis,
create event and causal factor trees, draw conclusions, and generate
recommendations that will reduce human error or mitigate the negative
consequence of human actions (Requirement 31317).

b\. Basic knowledge of physical and psychological processes,
capabilities, skill levels, and limitations of humans, such as the
science and practical application of cognitive psychology, human
reliability, anthropometrics, biomechanics, and human factors
engineering applications to design (Requirement 31318).

2.6.3 The Center safety office shall develop and maintain NASA mishap
investigation introductory training (onsite orientation training) that
can be provided to the investigating authority and advisors upon their
assignment to the investigation (Requirement 31319).

a\. The NASA mishap investigation introductory training shall include
(at a minimum) a brief familiarization of the investigating authority\'s
roles and responsibilities, NASA policy and procedures, and a
description of root cause analysis (Requirement 31320).

**2.7 Tools**

The Chief/OSMA supported by the Center safety offices shall identify
candidate mishap investigation tools that can be implemented quickly and
maintain a tool repository that makes these tools readily available to
investigating authorities (Requirement 31321).

**CHAPTER 3. Initial Response to a Mishap or Close Call**

> *Note: A notional timeline of the mishap investigation process, from
> the time of a mishap to the time that the corrective action plan and
> lessons learned are generated, is in Appendix C.*

**3.1 Safe the Mishap Site and Initiate Mishap Preparedness and
Contingency Plan(s)**

3.1.1 After the initial notifications are made, the supervisor shall
provide any necessary assistance to safe the mishap site until the
emergency response and/or personnel from the Center safety office arrive
(Requirement 31324).

3.1.2 Upon notification of a mishap, the Center safety office shall
initiate the Center Mishap Preparedness and Contingency Plan
(Requirement 31325).

3.1.3 In the event of a program/project mishap, the program shall
activate its Mishap Preparedness and Contingency Plan.

3.1.4 In accordance with the Center Mishap Preparedness and Contingency
Plan, the incident commander, with support from the responsible
organization, IRT, Center safety office, Center security office,
emergency response personnel, and supervisor, shall take immediate
action to prevent further injury to personnel and/or damage to any
property and secure the site (Requirement 31326).

3.1.5 The incident commander and emergency response personnel shall have
the authority to take action to mitigate dangerous conditions, direct
emergency response actions, and/or clean up a hazardous materials
release (Requirement 31327).

3.1.6 The Center safety office and incident commander shall ensure
protection of personnel from residual hazardous material prior to entry
into the mishap site (Requirement 31328).

3.1.7 The Center safety office and/or incident commander shall stipulate
the type of personal protective equipment (PPE) required (Requirement
31329).

3.1.8 Every professional supporting the investigation, including the IRT
and investigating authority, shall adhere to the PPE requirements as
defined by the Center safety office personnel or incident commander
(Requirement 31330).

**3.2 Notify Headquarters Office of Safety and Mission Assurance Within
1 Hour of Type A Mishap, Type B Mishap, High-Visibility Mishap, or
High-Visibility Close Call**

After emergency response has been initiated, within 1 hour of the
occurrence of a Type A mishap, Type B mishap, high-visibility mishap, or
high-visibility close call, the Center safety office shall notify
Headquarters as described in paragraph 1.5.3 and NPR 7100.1, paragraph
11.4.1 (Per NPR 7100.1, paragraph 11.4.1, this includes immediately
reporting a human test subject injury or fatality that resulted in a
loss of life, a permanent disability, hospitalization, extensive first
aid, or lost workday(s)) (Requirement 31332).

**3.3 Deploy IRT**

In accordance with the Center or program/project Mishap Preparedness and
Contingency Plan, the Center safety office or other designee shall
deploy the IRT to initiate and support the investigation until a
determination can be made as to the need for, and selection of, an
investigating authority (Requirement 31333).

**3.4 Notify Personnel and the Public of Potential Hazards**

The AA/OPA (or designee), with the assistance of the Center safety
office, IRT, and CD or AA/OIA shall immediately release information to
the press and media to alert Center personnel and the public of any
known hazards and their potential effects and provide instructions that
will mitigate the risk and harm (Requirement 31334).

**3.5 Secure the Site and Preserve Evidence**

3.5.1 The incident commander, with support from the responsible
organization, IRT, Center safety office, Center security office,
emergency response personnel, and supervisor, shall take immediate
action to prevent further injury to personnel and/or damage to any
property, secure the site, limit unnecessary access, and preserve
evidence (Requirement 31336).

3.5.2 Evidence preservation actions shall not hamper essential rescue
operations (Requirement 31337).

3.5.3 In the event that a fatality occurred, a Federal employee that is
part of the IRT (preferably a medical professional) or the physician
that serves as a member of the investigating authority shall coordinate
and consult with the Office of General Counsel and the coroner or
medical examiner to determine medical jurisdiction and arrange for
forensic analysis (i.e., autopsy) (Requirement).

**3.6 Impound Data**

3.6.1 The Center safety office, with the support of the IRT, Center
security office personnel, and supervisor, shall impound all appropriate
data, records, equipment, and facilities that may be involved in the
mishap to prevent their unauthorized use or modification (Requirement
31340).

3.6.2 The Center safety office shall control access to all impounded
items until they are released by the investigating authority per the
procedures in the Center Mishap Preparedness and Contingency Plan
(Requirement 31341).

3.6.3 Data and records, regardless of format, to be impounded may
include, but are not limited to, check-out logs, test and check-out
record charts, launch records, weather information, telemetry tapes,
video tapes, audio tapes, time cards, training records, work
authorization documents, inspection records, problem reports, notes,
e-mail messages, and automated log keeping systems and procedures.

3.6.4 For NASA mishaps occurring on international programs and/or
involving program participants, autopsies shall be conducted in
accordance with the bilateral/multilateral agreements (Requirement
31343).

3.6.5 For NASA mishaps occurring on international programs and/or
involving international program participants, data, records, equipment,
and facilities shall be impounded in accordance with the
bilateral/multilateral agreements (Requirement 31344).

**3.7 Initiate Drug Testing**

If the mishap results in a fatality or personal injury requiring
immediate hospitalization, or in damage estimated to be in excess of
\$10,000 to government or private property, the supervisor shall
initiate post-accident/unsafe practice testing per NPR 3792.1, NASA Plan
for a Drug-Free Workplace (Requirement 31345).

**3.8 Collect Witness Statements**

a\. All written witness statements obtained within the first 24 hours of
the occurrence of a mishap or close call shall be considered privileged
and protected (Requirement 31347). Where possible, written witness
statements should be collected on a NASA form that includes the
statement of privilege as shown in Figure 6.

b\. All verbal witness statements and written statements given after 24
hours as part of a NASA mishap investigation, where the witness was
explicitly informed that his/her account will not be released, shall be
considered privileged and protected (Requirement 31348).

c\. When privilege has been granted by the IRT, Center safety office, or
investigating authority, NASA shall make every effort to keep witness
testimony (both written and verbal) confidential and privileged to the
greatest extent permitted by law (Requirement 31349). This privileged
information will be strictly limited to only the information provided
directly by the witness for the safety investigation.

d\. The witness shall not be given a copy of the privileged written
statement or transcripts of verbal witness statements given in the
course of a NASA mishap investigation (Requirement 31350). (If witness
statements or transcripts of witness testimony are provided to a
witness, NASA cannot ensure that it remains privileged and
confidential.)

e\. The Center safety office, with the support of the IRT, shall either
request initial written statements from all persons who were involved in
or witness to the mishap or document verbal accounts from such persons
(Requirement 31351).

f\. Before a verbal witness statement is taken or an interview begins,
the IRT, Center safety office, or investigating authority shall tell the
witness whether the information gathered during the interview is
confidential and privileged or not confidential and not privileged
(Requirement 31352).

> *Note: If the same individual is interviewed multiple times, this
> should occur each time the individual is interviewed.*

g\. When conducting privileged witness interviews, the NASA
investigating authority shall only have Federal employees present at the
interview (with the exception of the interviewee), unless a contractor
has been hired specifically to support interviews or provide technical
guidance to the Board during the interviews and has signed a
nondisclosure agreement prepared by General Counsel prior to
participating in the interviews (Requirement).

h\. When it is expected that an external investigating body will be the
sole mishap investigation authority (e.g., for catastrophic vehicle
failure such as Space Shuttle or International Space Station loss, or
airplane loss), NASA shall not grant privilege to witnesses for either
written witness statements or verbal witness statements, even when those
statements are taken within the first 24 hours after the mishap
(Requirement).

> *Note: If an outside investigating authority, such as a
> congressionally appointed mishap investigating board or the National
> Transportation Safety Board (NTSB), conducts a mishap investigation
> for a mishap involving an airplane or catastrophic vehicle loss, they
> are not required to comply with NPR 8621.1. Consequently, NASA is
> unable to ensure that privilege will be maintained and may not be able
> to withhold privileged statements from the investigation authority.*

i\. When the IRT, Center safety office, or investigating authority
decides to take a verbal statement or interview a witness and keep that
witness interview confidential, the interviewer shall read the statement
in Figure 6 of this NPR and inform the witness that:

\(1\) The oral statement (taken during interview) and/or written
statement will be retained as part of the investigation report
background files but will not be released as part of the mishap report
(Requirement 31354).

\(2\) NASA will make every effort to keep the testimony privileged to
the greatest extent permitted by law (Requirement 31355).

######### Figure 6. Statement That Shall Be Read to Witness at the Start of the Formal Interview

+-----------------------------------------------------------------------+
| The purpose of this safety investigation is to determine the          |
| proximate cause(s) and root cause(s) of the mishap that occurred on   |
| \_\_\_\_\_\_\_\_\_\_\_\_\_ and to develop recommendations toward the  |
| prevention of similar mishaps. It is not our purpose to place blame   |
| or to determine legal liability. Your testimony is entirely           |
| voluntary, but we hope that you will assist the investigating         |
| authority to the maximum extent of your knowledge in this matter.     |
|                                                                       |
| Your testimony will be documented and retained as part of the mishap  |
| report background files but will not be released with your name as    |
| part of the mishap report.                                            |
|                                                                       |
| The investigating authority will make every effort to keep your       |
| testimony confidential and privileged to the greatest extent          |
| permitted by law.                                                     |
|                                                                       |
| For the record, please state your full name, title, address,          |
| employer, and place of employment.                                    |
+-----------------------------------------------------------------------+

3.9 Coordinate Release of Information

3.9.1 Release of Information Concerning Casualties and Extensive
Property Damage

3.9.1.1 The NASA Headquarters OPA must approve the release of all
information related to NASA Type A mishaps and Type B mishaps, prior to
its release to the press or public (Requirement 31362).

3.9.1.2 The CD or AA/OIA shall coordinate release of all information to
the press and the public via the Center PAO (Requirement 31360).

3.9.1.3 The Center PAO shall, as appropriate, disseminate any
preliminary information, video, and imagery to the public relating to
the mishap (Requirement 31361).

3.9.2 Release of Information Concerning NASA-Owned Property Damage on
Other Than Government-Owned Facilities, Overseas Tracking Stations, and
Contractor-Owned Plants

3.9.2.1 When a mishap involving extensive damage to, or destruction of,
NASA property occurs at other than government-owned facilities, overseas
tracking stations, or contractor-owned plants, the contractor, tracking
station manager, base commander, or other authority shall inform their
point of contact at NASA (Requirement 31364).

3.9.2.2 The Center safety office cognizant of the mishap shall confirm
that the mishap occurred to the NASA-owned property on other than
government-owned facilities (Requirement 31365).

3.9.3 Release of Information to the Press and Public Concerning
Casualties

3.9.3.1 NASA Employee Casualties. When a NASA employee is killed or
receives a permanent disability within the confines of a Center, the
Center PAO shall promptly announce to the public that a mishap has taken
place and injuries or fatalities have occurred (Requirement 30995).

a\. In the case of a fatality, the CD or AA/OIA or appropriate
Headquarters Official-in-Charge, shall ensure that notification of the
family has been made prior to release of the victim\'s name (Requirement
30996).

b\. All initial announcements shall include what is known at the time,
including the injuries or fatalities that have occurred and when
additional information is expected to be available (Requirement 30997).

c\. In the case of fatalities, release of the victim\'s name(s) shall be
made as soon as possible after the notification of the next of kin
(Requirement 30998).

3.9.3.2 Military and Other Agency Personnel Casualties. The procedures
for public announcements of mishaps involving military and other Federal
personnel (including astronauts) detailed to NASA shall be the same as
for NASA employees, with these additional requirements:

a\. The CD or AA/OIA shall inform the appropriate military service
headquarters or other Federal agency of the mishap (Requirement 31000).

b\. The CD or AA/OIA shall inform the Center PAO that the military
service organization or other Federal agency has been notified of the
mishap (Requirement 31001).

c\. When the Center is on a military base, release of a victim\'s name
shall be made according to procedures previously agreed upon by the base
commander and CD or AA/OIA (Requirement 31002).

3.9.3.3 Contractor and Grantee Employee Casualties. NASA does not assume
responsibility for the release of information concerning mishaps
involving contractor or grantee employees, except as follows:

a\. When a Type A mishap or Type B mishap occurs on a Center or at
Headquarters or involves a NASA-managed program managed by that Center,
the CD or AA/OIA, in coordination with the Center PAO/Headquarters PAO,
shall announce as soon as possible that a mishap has occurred, as well
as the number of known fatalities and/or injured (Requirement 31004).

b\. The CD or AA/OIA shall not announce the identity of contractor or
grantee personnel involved (Requirement 31005).

c\. When a mishap occurs at a contractor\'s/grantee\'s plant engaged in
NASA work, NASA has no responsibility to release information concerning
the mishap and shall not issue statements as to the cause and extent of
injury or damage (Requirement 31006).

3.9.3.4 Center Visitor Casualties. When a Type A mishap or Type B mishap
occurs which involves visitors on a Center or at Headquarters, the CD or
AA/OIA, in coordination with the Center PAO or Headquarters PAO, shall
announce as soon as possible that a mishap occurred and the number of
known fatalities and/or injured (Requirement 31007).

3.9.3.5 Overseas Mishaps. When a Type A mishap or Type B mishap occurs
overseas, for example, at a tracking station or during an overseas
rocket or balloon campaign involving NASA personnel, the
Official-in-Charge shall release mishap information through the U.S.
consular office in accordance with policies and procedures established
by that office (Requirement 31008).

a\. If the program involves foreign participation, the release of
information shall be coordinated with the foreign entities sponsoring
and participating in the program (Requirement 31009).

b\. The Official-in-Charge shall notify, by the most expeditious means,
the Chief/OSMA and the appropriate MDAA that a mishap has occurred
overseas (Requirement 31010).

c\. The MDAA shall notify, by the most expeditious means, the AA that a
mishap has occurred overseas (Requirement 31010).

d\. The AA shall immediately notify the Administrator, the Deputy
Administrator, the AA/OPA; the Assistant Administrator, Office of
External Relations; the Office of the General Counsel, as well as other
appropriate staff that a mishap has occurred overseas.

**3.10 Notify OSHA**

3.10.1 Within 8 hours of a work-related mishap involving death of a
Federal employee, or the hospitalization for inpatient care of three or
more employees (provided at least one is a Federal employee), the Center
safety office shall notify OSHA per paragraph 1.5.4 of this NPR
(Requirement 31012).

3.10.2 OSHA notification is required for any fatality and for three or
more hospitalizations for inpatient care that occur up to 30 workdays
after the respective mishap (Requirement 31671).

**3.11 Record the Mishap**

3.11.1 For Type A mishaps, Type B mishaps, high-visibility mishaps, and
high-visibility close calls, the Center safety office shall send an
electronic notification to OSMA/SARD containing information found in
paragraph 1.5.3.2 of this NPR (Requirement 31014).

3.11.2 Within 24 hours, the Center safety office shall ensure that all
NASA mishaps and close calls are recorded in IRIS in accordance with
paragraph 1.8.1 of this NPR (Requirement 31015).

> *Note: Close calls involving aircraft may be entered into the NAARS in
> lieu of IRIS.*

**CHAPTER 4. Select the Investigating Authority and Support**

**4.1 Determine the Appointing Official for Mishap and Close Call
Investigation**

4.1.1 The Chief/OSMA or the AA shall contact the Administrator within 1
hour of the initial notification of the Type A mishap to determine if
the Administrator wishes to exercise appointment authority (Requirement
31018).

4.1.2 Within 48 hours of a mishap or close call, the appointing
official, as specified in Figure 5, shall appoint the investigating
authority (Requirement 31019).

4.1.3 The Administrator shall serve as appointing official for NASA
joint participation on a MIB with the DoD and other agencies unless
authority is delegated by existing agreements (Requirement 31020).

**4.2 Select the Members of the Investigating Authority (MIB, MIT, or
MI)**

> *Note: Investigating Authority members include: chairperson, voting
> members, and ex officio. Support personnel, such as advisors and
> consultants, are not members of the investigating authority (MIB, MIT,
> or MI).*

4.2.1 The appointing official shall select the members of the
investigating authority, the chairperson, the executive secretary (when
needed), and the support staff (Requirement 31022).

4.2.2 The MDAA shall request concurrence from the Chief/OSMA and the
Chief Engineer on the proposed MIB membership for Type A mishaps,
high-visibility mishaps, and high-visibility close calls in which he/she
is the appointing official (Requirement 31023).

4.2.3 For Type A mishaps and Type B mishaps, the investigating authority
membership shall be determined with the advice of the Office of the
General Counsel or the Office of the Chief Counsel, as appropriate
(Requirement 31024).

4.2.4 For Type A mishaps and Type B mishaps, high-visibility mishaps,
and high-visibility close calls involving aircraft, the investigating
authority membership shall be determined with the advice of the AMD
(Requirement 31024).

4.2.5 The Chief/OSMA shall concur with the selection of MIB membership
for Type A mishaps, Type B mishaps, high-visibility mishaps, and
high-visibility close calls (Requirement 31025).

4.2.6 For Type C mishaps, Type D mishaps, and close calls, the CD or
AA/OIA, or designee, shall seek advice concerning investigating
authority membership from the Center safety office (Requirement 31026).

a\. The MDAA \[or designee\] shall seek advice concerning investigating
authority membership from OSMA/SARD for NASA Type C mishaps, Type D
mishaps, and close calls that involve Mission Directorate
programs/projects/activities where the mishaps or close calls have
occurred outside the Center\'s gates and are not managed by a Center,
program, or project (Requirement 31027).

4.2.7 The appointing official shall use the following requirements to
determine the composition of the investigating authority:

a\. All members of the investigating authority (including the
chairperson) and the executive secretary must be Federal personnel
(Requirement 31029).

b\. The severity and complexity of the mishap to be investigated shall
dictate the total number of members (Requirement 31030).

c\. The investigating authority shall consist of an odd number of voting
members (including the chairperson) (Requirement 31031).

d\. The majority of the members of the investigating authority shall be
independent from (have no responsibilities for) the operation or
activity (Requirement 31032).

> *Note: During a mishap investigation, root cause analysis may evaluate
> actions of those performing the activity or overseeing the activity.
> It is difficult to conduct an unbiased investigation of one's own
> actions*.

e\. Members and the chairperson shall have the requisite security
clearances as identified in the Center and/or program/project Mishap
Preparedness and Contingency Plans (Requirement 31033).

f\. The chairperson for the investigating authority shall be independent
of the program or facility that experienced the mishap or close call
(Requirement).

> *Note: It is preferred, for Type A mishaps and Type B mishaps, that
> the chairperson is not from a Center directly involved in the
> oversight or assurance of the program or facility operation.*

g\. The members shall not be 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 (Requirement 31034).

h\. The MIB and MIT shall be composed of a chairperson, members, and an
ex officio (Requirement 31035).

i\. The MIB shall have at least five members for a Type A mishap and at
least three members for a Type B mishap (Requirement 31036).

\(1\) The number of MIB members for high-visibility mishaps and
high-visibility close calls shall be determined by the appointing
official (Requirement 31037).

j\. For all Type A mishaps involving injury, illness, or fatality, the
MIB shall include an occupational health physician as a member
(Requirement 31038). (Mishaps involving an aircraft may have a flight
surgeon rather than an occupational health physician.)

> *Note: The chairperson may request a medical doctor to serve as an
> advisor or consultant, if one is not a member of the mishap
> investigation board.*

k\. For all Type A mishaps, Type B mishaps, high-visibility mishaps, and
high-visibility close calls involving aircraft, the MIB shall have a
member knowledgeable in aircraft operations, a member knowledgeable in
aircraft maintenance, and a member knowledgeable in aviation safety
(Requirement 31039). (The member knowledgeable in aviation safety may
serve as the safety officer.)

l\. The MIB and MIT shall include a safety officer and a human factors
mishap investigator as members (Requirement 31040).

m\. All investigating authorities are encouraged to have an independent
member from an external Federal agency.

n\. The investigating authority shall have at least one member that has
completed all the NASA mishap investigation training listed in paragraph
2.6.1.a in the last 1 year and paragraph 2.6.1.b in the last three years
(Requirement 31042).

o\. When possible, all investigating authority members should be
selected from personnel who have completed the NASA mishap investigation
training (or equivalent) and have received refresher training in the
last 3 years (if training was acquired more than 3 years ago).

p\. Members shall have sufficient experience and technical expertise to
understand the technology and management interfaces related to the
mishap (Requirement 31044).

q\. When needed, if the area of investigation expertise can not be
obtained within NASA, the investigating authority\'s members may be
appointed from Federal agencies having technical expertise in the area
of investigation.

r\. For international programs, members shall be selected as described
in bilateral/multilateral or international agreements (Requirement
31046).

s\. As documented in the Center Mishap Preparedness and Contingency
Plan, the supervisor may serve as the investigating authority (mishap
investigator) for Type D mishap and close calls in his/her organization
as long as the following are true:

\(1\) The close call has not been deemed "high visibility" by the Center
safety office, CD, or a higher authority.

\(2\) The supervisor has received introductory training on NPR 8621.1,
root cause analysis, and investigating close calls and mishaps.

\(3\) The safety office assigns a person to serve as the ex officio to
ensure that the investigation and report is nonpunitive and that the
report meets the requirements in NPR 8621.1.

\(4\) The safety office assigns a person to endorse the mishap report.

**4.3 Select the Ex Officio**

4.3.1 For any mishap or close call, the Chief/OSMA may serve as the ex
officio or appoint, at his/her discretion, the ex officio; otherwise
that selection shall be made by the senior SMA official in the
appointing official\'s organization (Requirement 31048).

4.3.2 For Type C mishaps, Type D mishaps, and close call investigations,
the ex officio shall be at a level consistent with the authority level
of the MIT chair (Requirement 31049).

> *Note: For investigations completed by a single mishap investigator,
> an ex officio is not required.*

4.3.3 The ex officio shall be a Federal employee selected from personnel
who have completed the NASA mishap investigation training or equivalent
and have received refresher training in the last 3 years (if training
was acquired more than 3 years ago) (Requirement 31050).

4.3.4 For Type C level investigations and below, the ex officio function
may be fulfilled by a professional from the Center safety office who
participates in the investigation activities he or she deems appropriate
and approves the mishap report demonstrating assurance that the
conditions in paragraph 1.4.12.d of this NPR have been met.

4.3.5 Only one ex officio shall be appointed to an investigating
authority (Requirement 31052).

**4.4 Select Investigating Authority\'s Advisors**

4.4.1 For all mishaps, the appointing official shall request that the
appropriate mission support office appoint advisors to the investigating
authority (Requirement 31054).

4.4.2 For Type A, Type B, and Type C mishaps, the investigating
authority shall have a legal advisor, a public affairs advisor, an
import/export control advisor, and (where appropriate) an external
relations advisor (Requirement).

4.4.3 The advisors shall be NASA civil service employees selected from
the respective mission support offices and be authorized to represent
their mission support office\'s interests in the investigation
(Requirement 31055).

4.4.4 When possible, the advisors should be selected from personnel who
have completed the NASA mishap investigation training or equivalent and
have received refresher training in the last 3 years (if training was
acquired more than 3 years ago).

**4.5 Select Investigating Authority\'s Consultants**

4.5.1 Non-Federal employees may serve as consultants to the
investigating authority.

4.5.2 When possible, consultants should be selected from personnel who
have completed the NASA mishap investigation training or equivalent and
have received refresher training in the last 3 years (if training was
acquired more than 3 years ago).

4.5.3 As appropriate, consultants should have sufficient experience and
technical expertise to understand the technology and management
interfaces related to the mishap.

**4.6 Provide Support to Investigating Authority**

4.6.1 The appointing official shall arrange for administrative,
logistical, and information technology support to the investigating
authority via the appointment letter or by contacting the appropriate CD
or the AA/OIA, as appropriate (Requirement 31372). Administrative
support may include, but is not limited to, meeting rooms, clerical
help, photographic support, records management assistance, and
laboratory analysis.

4.6.2 The responsible organization, the Center safety office, and the CD
or AA/OIA shall provide support as deemed necessary by the investigating
authority (Requirement 31373).

**4.7 Contents of the Appointment Letter or Appointment Orders**

4.7.1 For Type A mishaps, Type B mishaps, high-visibility mishaps, and
high-visibility close calls, the appointing official shall prepare an
appointment letter to communicate the selection of the investigating
authority members, the chairperson, the ex officio, and the advisors
(Requirement 31375). (For Type C mishaps, Type D mishaps, and close
calls, the appointment orders can be less formal and communicated via a
Center process.)

4.7.2 The appointment letter shall identify the chairperson, membership
(including ex officio), the legal advisor, the Headquarters public
affairs advisor, import/export control advisor, the external relations
advisor (where appropriate), the scope of the investigation, and the
projected completion date (Requirement 31376).

4.7.3 The appointment letter/appointment orders shall relieve the
investigating authority chairperson and members from other duties while
they are engaged in investigation activities (Requirement 31377).

**CHAPTER 5. Mishap Investigation Process**

**5.1 Overview of the Mishap Investigation Process**

5.1.1 The investigating authority shall use a structured technique to
collect and review all available data, construct a timeline of events,
conduct witness interviews, reconstruct the mishap or close call, and
analyze the mishap occurrence to determine what happened, when it
happened, and why it happened (Requirement 31380).

5.1.2 Figure 7 illustrates the typical steps that the investigating
authority shall perform during the mishap investigation (Requirement
31381).

######### Figure 7. Typical Steps in the Mishap Investigation

5.2 Prepare for the Investigation

The investigating authority shall perform the following activities prior
to arrival at the mishap site or shortly thereafter:

a\. Mishap investigation overview training (Requirement 31382).

\(1\) The Investigating Authority members and advisors shall take the
NASA "Introduction to Mishap Investigation Training" upon their
assignment to the investigation to familiarize themselves with NASA
mishap investigation policies and procedures and root cause analysis
(Requirement 31383). (Investigating authority members and advisors may
opt out of the training if they have taken it within the last 12
months.)

b\. Assessment of personnel resources (Requirement 31384). The
chairperson may make a request to the appointing official to modify the
investigating authority\'s membership to fill technical and/or
analytical expertise gaps, provide management experience and knowledge,
or eliminate members that have a conflict of interest.

\(1\) For Type A mishaps, Type B mishaps, high-visibility mishaps, and
high-visibility close call investigation boards, the Chief/OSMA and
Chief Engineer shall concur on membership changes prior to any MIB
member additions or deletions (Requirement 31385).

c\. Identification and selection of consultants as necessary
(Requirement 31386).

d\. Establishment of member duties, meeting times, and investigation
schedules (Requirement 31387).

**5.3 Verify that the Site is Safe and Secured and Ensure Evidence is
Preserved/Impounded**

5.3.1 Verify that the Mishap Site is Safe and Secured.

5.3.1.1 Upon arrival, the chairperson shall verify the site is safe and
secured (Requirement 31390).

5.3.1.2 Neither the investigating authority nor the IRT has the
authority to direct emergency response actions or activities to clean up
a hazardous materials release (Requirement 31391).

\(1\) These actions shall be directed by the incident commander
(Requirement 31392).

5.3.2 Ensure that Evidence is Preserved and Impounded.

5.3.2.1 The chairperson shall ensure that all the appropriate perishable
evidence has been collected, photographed, documented, and/or impounded
(Requirement 31394).

5.3.2.2 The chairperson shall ensure that all the necessary data,
records, and equipment have been impounded and are being stored in a
secure site (Requirement 31395).

5.3.2.3 The IRT, Center safety office personnel, emergency response
personnel, and Center security office personnel shall provide the
investigating authority with all evidence gathered at the scene; all
data pertaining to the investigation, including impounded records; a
status of impounded records/equipment; and a description of the actions
taken (Requirement 31396).

5.3.2.4 When there is a mishap involving an injury or a fatality, the
chairperson shall appoint a Federal employee to serve as an evidence
custodian(s) who will implement the "chain of custody process"
documented in the Program Mishap Preparedness and Contingency Plan to
provide physical security over and controlled access to the
injured/deceased personal effects and related sensitive material
(Requirement).

**5.4 Gather Physical Evidence and Facts**

5.4.1 The investigating authority should evaluate three general sources
of data (material, personnel, and records) during the investigation. The
material area includes all parts, components, and support facilities
directly or indirectly involved. The personnel area includes all persons
associated with the activities immediately surrounding the mishap, such
as the flight crew, launch complex personnel, maintenance personnel,
test personnel, operations personnel, range safety personnel, management
and supervisory personnel, and witnesses and their associated training
records, certification, e-mail, notes, and other records. The records
data, regardless of format, include all records, telemetry, recordings,
analyses, inspections, and historical data associated with the specific
equipment, operations, and operating personnel.

5.4.2 The investigation should not be limited to data and records
generated concurrently with, or as a result of, the mishap. It should
also include historical, environmental, operational, psychological, and
other factors bearing on the situation.

5.4.3 Lack of physical evidence. If there is no recoverable physical
evidence available, the investigating authority shall use existing
program and/or mission documentation, any collected mission data, and
applicable analytical techniques to determine the probable proximate
cause(s) and probable root cause(s) of the mishap (Requirement 31400).

**5.5 Interview Witnesses**

5.5.1 It is NASA\'s philosophy to interview witnesses rather than
interrogate them. \"Interview\" connotes a cooperative meeting where the
interviewer approaches the interviewee as an equal. The cooperation of
the interviewee is sought; encouragement is given to tell the story
freely without interruption or intimidation. An interview is usually
conducted informally with a voluntary or cooperative answering of
questions. However, the investigating authority may also conduct more
formal interviews. Even in those cases, witnesses shall not be sworn in
(Requirement 31402).

5.5.2 The investigating authority shall interview mishap witnesses with
two basic objectives in mind:

a\. To find out what the witness observed or did (Requirement 31404).

b\. To find out the witness\'s opinion of potential cause(s) of the
mishap (Requirement 31405).

5.5.3 The investigating authority conducting the witness interviews
shall perform all steps as listed in paragraph 3.8 of this NPR
(Requirement 31406).

**5.6 Review and Analyze Data**

5.6.1 The investigating authority shall determine the sequence of events
and document them in a timeline (Requirement 31408).

5.6.2 The investigating authority shall create a fault tree, or perform
an equivalent analysis, to identify all potential cause(s) and
contributing factor(s) to the mishap and the relationships among them
(Requirement 31409).

> *Note: A fault tree should be used by the MIB to demonstrate that all
> potential causes of the mishap have been evaluated. An event and
> causal factor tree should be used to represent all the events that did
> occur, and the relationship between the proximate, intermediate, and
> root causes.*

5.6.3 The investigating authority shall analyze all potential cause(s),
including both technical and human cause(s) (Requirement 31410).

**5.7 Draw Conclusions and Document Findings**

5.7.1 The investigating authority shall evaluate all information
collected during the course of the investigation, including, but not
limited to, physical evidence, witness statements and testimony, and
analytical results from testing and analysis; draw conclusions
concerning what happened and why it happened; and document these as
investigation findings (Requirement 31412).

5.7.2 All findings shall be supported by facts (Requirement 31413).

**5.8 Generate Recommendations**

5.8.1 At a minimum, the investigating authority shall develop
recommendations that address both the proximate cause(s) and the root
cause(s) to prevent recurrence of the mishap or close call or similar
mishaps and close calls (Requirement 31415).

5.8.2 The investigating authority shall verify that the recommendations
are practical, feasible, and achievable (Requirement 31416).

5.8.3 The investigating authority shall prioritize the recommendations
(Requirement 31417).

5.8.4 At any time during the investigation, the investigating authority
may recommend to the appointing official that immediate corrective
actions be taken to ensure the safety of ongoing operations internal or
external to NASA.

5.8.5 Upon receipt of a safety critical recommendation, the appointing
official shall evaluate the recommendation and communicate the
recommendation to the responsible program, project, organization, or
external body to initiate implementation of corrective measures
(Requirement 31419).

**5.9 When and How to Turn Over for Criminal Investigation**

If it is reasonably suspected that a mishap resulted from criminal
activity, the investigating authority shall halt the investigation;
notify immediately the OIG and the Office of the General Counsel or the
Office of the Chief Counsel, as appropriate; notify the appointing
official; and wait for further direction (Requirement 31420). (The
safety investigation should be completed regardless of the initiation of
collateral investigations.)

**5.10 Release the Mishap Site and Restore Site Operations**

5.10.1 Only the investigating authority shall release the mishap site
for post-investigation cleanup or other activities (Requirement 31422).

5.10.2 Only the investigating authority shall release impounded data,
records, equipment, or facilities (Requirement 31423).

5.10.3 The investigating authority shall not release data and records
unless copies of the documents are made and retained with mishap
investigation records (Requirement 31424).

**CHAPTER 6. Mishap Report**

**6.1 Develop the Mishap Report**

6.1.1 The investigating authority shall develop a mishap report that
contains the information as specified in paragraph 1.7 and Figure 5 in
this NPR (Requirement 31427).

6.1.2 Witness statements, witness names, and names of those involved in
the mishap or related activities shall not be included as a part of the
mishap report (Requirement 31428).

6.1.3 The mishap report shall be technically accurate; properly
documented; easily understood; have traceability between facts,
findings, and recommendations; and include the products required in
Figure 5 in this NPR, in the following order:

a\. Section 1: Signature page(s), list of consultants, executive
summary, and OSHA summary (when applicable) (Requirement 31430).

b\. Section 2: Narrative description and facts (what, when, where, how)
(Requirement 31431).

c\. Section 3: Type of data gathered and data analysis (level of detail
and products dependent upon Figure 5 in this NPR) (Requirement 31432).

d\. Section 4: Finding(s) (Requirement 31433).

e\. Section 5: Recommendation(s) (Requirement 31434).

f\. Section 6: Minority Report(s) (Requirement 31435).

6.1.4 The investigating authority shall include the mishap
classification level (e.g., Type A, Type B, Type C, Type D, or close
call) and the IRIS/NAARS case number in the mishap report title page and
the report executive summary (Requirement).

6.1.5 The investigating authority shall describe, in the mishap report,
the type of property damage, type of the mission failure, and/or
describe the personal injury(ies)/illness/(es) (Requirement).

6.1.6 The investigating authority shall describe, in the mishap report,
the actual direct cost of the mishap or if the actual direct cost is not
available, the estimate of the direct cost of the mishap (Requirement).

6.1.7 In the event that the investigating authority does not reach
agreement on findings or recommendations, any member may develop and
attach a minority report to the mishap report.

6.1.8 If the investigating authority would like to receive a preliminary
review of the mishap report and feedback concerning the adequacy of the
report, they may provide a draft mishap report to the appointing
official and request a preliminary review.

a\. This preliminary review must occur within the time allocated for the
completion of the mishap report (Requirement 31438).

b\. Upon receipt of a draft mishap report, the appointing official shall
determine the appropriate preliminary review process and reviewing
offices that should participate in the preliminary review, have them
review the draft mishap report, and provide feedback to the
investigating authority within 15 workdays (Requirement 31439).

c\. The Center safety office or OSMA (dependent on level of
investigation) shall participate in all preliminary reviews (Requirement
31440).

d\. Feedback from reviewers may include, but is not limited to, requests
for clarification, additional facts, further root cause analysis (or
other analysis), feasibility evaluation of recommendations, compliance
with NPR, and/or removal (or placement in a nonreleasable appendix) of
privileged or proprietary information, ITAR information, EAR
information, material subject to the Privacy Act, or other inappropriate
information (i.e., witness names).

e\. The chairperson and/or investigating authority is not required to
make any changes to the mishap report with which he or she does not
agree (Requirement 31442).

6.1.9 All investigating authority members shall sign the completed
mishap report (Requirement 31443).

6.1.10 The ex officio shall sign the completed mishap report attesting
to the following:

a\. The investigation was conducted in conformance with NASA policy and
this NPR (Requirement 31445).

b\. The investigation process was fair, independent, and nonpunitive
(Requirement 31446).

c\. The mishap report contains all the required elements (Requirement
31447).

d\. The mishap report accurately identifies the proximate cause(s), root
cause(s), and contributing factor(s) (Requirement 31448).

e\. Adequate facts have been gathered and analyzed to substantiate the
findings (Requirement 31449).

f\. The recommendations reasonably address the causes and findings
(Requirement 31450).

g\. The recommendations track one-to-one to each significant finding
(Requirement 31451).

h\. If these conditions have not been met, the ex officio shall describe
the mishap report\'s deficiencies in writing and sign and attach this
description to the mishap report in lieu of signing the report
(Requirement 31452).

6.1.11 Each NASA advisor shall sign the mishap report stating that
he/she has reviewed the mishap report, that it meets NASA policies and
procedures in his/her functional area (Requirement 31155) and:

a\. The export control advisor's signature indicates that any ITAR
information and EAR information has been identified and marked as
non-releasable to the public (e.g., NASA Sensitive But Unclassified).

b\. The contracting officer's signature indicates that any proprietary
information or material subject to the Privacy Act has been identified
and marked as non-releasable to the public (e.g., NASA Sensitive But
Unclassified).

c\. The legal advisor's and public affairs advisor's signature indicates
that any privileged or proprietary information, ITAR information, EAR
information, or material subject to the Privacy Act has been identified
and marked as nonreleasable to the public (e.g., NASA Sensitive But
Unclassified); and that volumes/appendices that are releasable to the
public are marked releasable.

> *Note: Although marked, this release is pending endorsements and
> Public Affairs Office authorization.*

6.1.12 The names of the consultants may be listed in the mishap report;
however, the consultants shall not sign the mishap report (Requirement
31454).

6.1.13 Within 75 workdays of the mishap or close call, the investigating
authority shall submit the completed and signed mishap report to the
appointing official (Requirement 31455).

> *Note: Until this report has been signed and is officially endorsed by
> the endorsing officials, it is not an "official NASA Mishap Report"
> and should not be distributed to anyone other than the investigating
> authority, appointing official, endorsing officials, their reviewers,
> and the Headquarters SMA Mishap Coordinator.*

6.1.14 If the investigating authority needs additional time to complete
the investigation and/or the mishap report, they may submit a verbal or
written request to the appointing official.

**6.2 Release Investigating Authority**

Upon receiving the signed mishap report, the appointing official shall
inform the investigating authority that the mishap report fulfills the
requirements of the appointment letter and that they are released from
duty (Requirement 31457).

**6.3 Review, Endorse, and Approve Mishap Report**

6.3.1 Upon receipt of the signed mishap report, the appointing official
shall request the appropriate officials to review and endorse the mishap
report (see Figure 5 of this NPR for endorsing officials) (Requirement
31459).

6.3.2 The review and endorsement process should verify, at a minimum,
the following:

a\. The mishap report content is technically accurate and complete
(Requirement 31461).

b\. Proper analysis techniques were selected and completed correctly
(Requirement 31462).

c\. The mishap report adequately describes proximate cause(s), root
cause(s), and contributing factor(s) (Requirement 31463).

d\. There are adequate facts to substantiate the findings (Requirement
31464).

e\. Recommendations track one-to-one to each finding (Requirement
31465).

f\. Recommendations are practical, feasible, achievable, and will, in
the opinion of the reviewer, prevent recurrence of similar mishaps or
close calls (Requirement 31466).

g\. Proprietary information, ITAR information, EAR information, material
subject to the Privacy Act, or privileged information that should not be
released has been identified (Requirement 31467).

6.3.3 For those mishap or close call reports where the Chief/OSMA is an
endorsing official, all endorsements shall be forwarded to OSMA for
review prior to completion of the Chief/OSMA endorsement (Requirement).

6.3.4 Within 30 workdays, the endorsing officials will provide their
signed endorsement, recommendation for mishap report approval or
rejection, and (when applicable) comments related to amplification or
disagreement with elements of the report to the appointing official.
(These endorsements and comments (when applicable) shall be attached to
the mishap report and become part of the permanent record) (Requirement
31468).

6.3.5 Within 5 workdays, the appointing official shall attach all
endorsements and comments (including his/her own) to the mishap report,
review the comments, and determine if the report is approved or rejected
based on the review and comments/direction from endorsing officials
(Requirement 31469).

6.3.6 If the appointing official rejects the mishap report, he/she must
provide a written description of the deficiencies that warrant this
rejection, attach this to the mishap report, send the report to the
Center safety office (or OSMA for Type A mishaps, Type B mishaps,
high‑visibility mishaps, and high-visibility close calls) for records
retention, and charter a new investigation (Requirement 31470).

**6.4 Authorize Mishap Report for Public Release**

6.4.1 If the mishap report is approved, the appointing official shall
immediately send the approved report with endorsements/comments to the
Export Administrator, the Center PAO, Office of Security and Program
Protection, and then to OPA, Procurement, and legal counsel for review
(Requirement 31472).

> *Note: For Type D mishaps and Close Calls, the Center Director, via
> documentation in the Center Mishap Preparedness and Contingency Plan,
> may allow the authorization for public release to occur only after a
> Freedom of Information Act (FOIA) request is made. However, this does
> not negate the responsibility to place lessons learned into the
> lessons learned information system.*

6.4.2 Within 10 workdays of the request, the Export Administrator, OPA,
Office of Security and Program Protection, Procurement, and legal
counsel shall review the mishap report and specify in writing which
sections of the mishap report are authorized for public release
(Requirement 31473).

> *Note: The Office of Security and Program Protection role is to review
> the report to determine if any information in the report should be
> classified Secret or Top Secret.*

**6.5 Distribute Mishap Report**

6.5.1 Upon receipt of notification that the mishap report is authorized
for public release, the appointing official shall send the approved
mishap report with authorization comments to OSMA/SARD and the Center
safety office (dependent upon level of investigation) (Requirement
31475).

6.5.2 Within 10 workdays, the MDAA or the Center safety office shall
distribute the mishap report to the appropriate NASA programs and
organizations including, but not limited to, the responsible
organization and/or program, all Center safety offices, the CHMO (when
an injury or fatality has occurred), and AMD (when the mishap involved
an aircraft) (Requirement 31476).

6.5.3 Within 15 workdays, the Center safety office shall distribute
information about the Type A mishap or Type B mishap via \"weekly safety
highlights\" (or equivalent) to Center personnel, including a brief
description of what caused the mishap and how it can be prevented
(Requirement 31477).

6.5.4 The AA/OPA shall determine whether a mishap report, whatever its
origin, shall be issued from Headquarters or the Center (Requirement
31478).

6.5.5 Generally, the appropriate public affairs officer shall make the
news release on the mishap report available simultaneously at
Headquarters and the appropriate Center (Requirement 31479).

6.5.6 The appropriate public affairs officer shall make the mishap
report available to the public at the same time (Requirement 31480).

6.5.7 For aircraft mishaps, final submittal of the NASA mishap reports
to the NTSB will be made by the Office of Institutions and Management.
The Office of Institutions and Management will ensure that the NTSB
submission meets the essential information required by the NTSB and may
reformat and streamline the approved NASA report as necessary to meet
that need without changing the report\'s causes, findings, and
conclusions.

6.5.8 Within 48 hours of a mishap or close call, NASA shall provide all
NASA employees and contractors access to information that is releasable
to the public via a database including date, location, and brief
description of the event.

6.5.9 As the mishap or close call record is updated, the employees will
be given access to the updated information that is releasable to the
public, including the executive summary, findings, and recommendations.

**CHAPTER 7. Post-Investigation Activities**

**7.1 Develop CAP**

7.1.1 Immediately after the mishap report has been authorized for public
release, the appointing official shall direct the responsible
organization or program/project to develop a CAP for those
recommendations approved by the endorsing officials (Requirement 31484).

7.1.2 The appointing official may extend the CAP deadline upon written
request from the responsible organization or program/project.

7.1.3 Within 15 workdays from being tasked, the responsible organization
or program/project shall develop and submit the CAP to the appointing
official (Requirement 31486).

**7.2 CAP Contents**

7.2.1 The CAP shall include the following:

a\. A description of the corrective actions along with a designation of
the organization(s) responsible for implementing the corrective actions
and a completion date for each corrective action (Requirement 31489).

b\. Which NASA organization, contractor organization, or grantee
organization (to the lowest level) is responsible for ensuring the
corrective action is completed (Requirement 31490).

c\. A matrix or other means of matching corrective actions to all
findings and recommendations (Requirement 31491).

d\. A review of any process changes required based on corrective actions
(Requirement 31492).

**7.3 Review and Approve CAP**

7.3.1 The appointing official may provide the CAP to the investigating
authority, applicable safety organization, and other selected offices as
is deemed appropriate for review.

7.3.2 Based on the results of these reviews and his/her own review, the
appointing official shall either accept or reject the CAP (Requirement
31495).

7.3.3 If the plan is rejected, the appointing official shall return the
CAP, with comments, to the responsible organization or program/project
for revision and resubmission (Requirement 31496).

7.3.4 The appointing official shall determine the timeframe for
resubmission of the CAP (Requirement 31497).

**7.4 Implement CAP**

7.4.1 The responsible organization shall implement the corrective
actions as directed by the appointing official and as documented in the
approved CAP (Requirement 31499).

7.4.2 The responsible organization shall track the corrective action
performance and completion in IRIS and inform the appointing official of
the status of the actions at intervals determined by the appointing
official (Requirement 31500).

7.4.3 Close calls involving aircraft that have been entered into the
NAARS, in lieu of IRIS, must track the corrective action performance and
completion in NAARS.

7.4.4 The Center safety office shall assist the responsible
organization, if needed, to enter updates into IRIS, as described in the
Center Mishap Preparedness and Contingency Plan (Requirement 31501).

7.4.5 The Center safety office shall enter into IRIS the actual direct
cost of the mishap or if the actual direct cost is not available, the
estimate of the direct cost of the mishap (Requirement).

7.4.6 Should a need arise to change the CAP after it has been approved
(because the actions are deemed unwise or not feasible), the responsible
organization shall submit the change to the appointing official for
approval, similar to the process used for the original plan approval
(Requirement 31502).

7.4.7 The appointing official shall assess and, if warranted and
desired, approve any changes to the CAP (Requirement 31503).

7.4.8 The appointing official shall send approved changes to the
responsible organization and the Center safety office (Requirement
31504).

**7.5 Monitor and Closeout CAP**

7.5.1 The applicable Center safety office shall monitor corrective
action activities to determine if they were carried out according to the
plan and report noncompliance to the appointing official (Requirement
31506).

7.5.2 When the corrective actions are closed, the appointing official
shall develop and provide a CAP closure statement to the supporting
Center safety office and the responsible organization to notify them
that the corrective action plan is closed (Requirement 31507).

7.5.3 The Center safety office shall verify that the CAP is complete and
all elements of the investigation have been completed and correctly
recorded in IRIS (or NAARS for aviation close calls using NAARS in lieu
of IRIS) (Requirement 31508).

**7.6 Develop, Disposition, Submit, and Approve Lessons Learned**

7.6.1 Following the authorization of the mishap report for public
release, the appointing official shall designate a person or team of
persons to develop the lessons learned identified in the mishap report
(Requirement 31510).

7.6.2 The individual or team shall develop lessons learned that, at a
minimum, include the executive summary, findings, and recommendations
from the mishap report that are authorized for public release.
(Requirement 31511).

7.6.3 Program and/or project managers that have mission failures or NASA
mishaps for long-duration missions shall develop lessons learned for
possible application to existing or future programs (Requirement 31512).

7.6.4 Within 10 workdays of being tasked, the person or team assigned to
develop lessons learned shall submit the prepared lessons learned to the
appointing official (Requirement 31513).

7.6.5 Prior to submission into NASA Lessons Learned Information System
(LLIS), NASA program and policy officials, including, but not limited
to, legal, import/export control, and public affairs, shall:

a\. Review the proposed lessons learned to ensure they are consistent
with NASA policy and do not contain any privileged or proprietary
information, ITAR information, EAR information, or material subject to
the Privacy Act (Requirement 31515).

b\. Provide the appointing official with a written statement indicating
that the lessons learned are cleared for submission into the NASA LLIS
(Requirement 31516).

7.6.6 Based on the results of the review of the lessons learned, the
appointing official shall either accept or reject the lessons learned
and forward accepted lessons learned to the NASA LLIS (Requirement
31517).

7.6.7 OCE and program managers shall review the LLIS quarterly to
determine if any mishap lessons learned should be translated into
programmatic or Agency requirements (Requirement).

**7.7 Conclude Mishap Activities**

7.7.1 The appointing official shall submit the mishap activities
completion statement to the responsible organization, OSMA/SARD (For
Type A mishaps, Type B mishaps, high-visibility mishaps, and
high-visibility close calls), the Center safety office, and other
appropriate organizations indicating that the investigation was
performed; the CAP was developed, implemented, and closed; and the
lessons learned have been entered into the NASA LLIS (Requirement
31519).

7.7.2 Once the appointing official has delivered the mishap activities
completion statement, his/her duties for the mishap investigation are
concluded, and the mishap file is closed.

**7.8 Record and Retain Evidence**

7.8.1 The final CAP and approved lessons learned shall be filed with the
official approved mishap report in a location specified in the Center
Mishap Preparedness and Contingency Plan (Requirement 31522).

7.8.2 NASA medical reports and witness statements are excluded from a
mishap report, but should be retained, marked confidential and
privileged, and filed with the official approved mishap report.

7.8.3 The CAP, lessons learned, and witness statements, plus other
records documenting the investigation, shall be managed and
dispositioned by the Center safety office in accordance with NPR 1441.1,
NASA Records Retention Schedule (Requirement 31524). Such records,
regardless of format, include, but are not limited to, mishap reports
and associated records; relevant notes and e-mail messages of the IRT
and investigation authority; meeting agendas, minutes, and other
documentation of the investigation process; and copies of all data and
records that are used in evaluation and analysis of the mishap.

**Appendix A. Terms and Definitions**

[Aircraft Mishap]{.underline}. An aircraft mishap is an occurrence
associated with the operation of an aircraft, which takes place between
the time any person boards the aircraft with the intention of flight and
all such persons have disembarked, and in which any person suffers a
fatality or serious injury, or in which the aircraft receives
substantial damage.

[Appointing Official]{.underline}. The official authorized to appoint
the investigating authority for a mishap or close call, to accept the
investigation of another authority, to receive endorsements and comments
from endorsing officials, and to approve the mishap report.

[Barrier]{.underline}. A physical device intervention (e.g., a
guardrail) or an administrative intervention that can provide procedural
separation in time and space (i.e., lock-out/tag-out procedure) that is
used to reduce risk of the undesired outcome to an acceptable level.

[CAP Closure Statement]{.underline}. A final statement made by the
appointing official that documents that all corrective actions have been
completed and the CAP is closed.

[Cause]{.underline}. An event or condition that results in an effect.
Anything that shapes or influences the outcome.

[Center Safety Office]{.underline}. The Center or Headquarters safety
organization responsible for reporting and recording mishaps.

[Chairperson]{.underline}. The individual in charge of a mishap
investigation board or mishap investigation team.

[Close Call]{.underline}. An event in which there is no injury or only
minor injury requiring first aid and/or no equipment/property damage or
minor equipment/property damage (less than \$1000), but which possesses
a potential to cause a mishap.

[Cognizant Center Safety Office]{.underline}. The safety office of the
Center that hosts the project or that has been assigned SMA
responsibilities for the program.

[Condition]{.underline}. Any as-found state, whether or not resulting
from an event, that may have safety, health, quality, security,
operational, or environmental implications.

[Contributing Factor]{.underline}. An event or condition that may have
contributed to the occurrence of an undesired outcome but, if eliminated
or modified, would not by itself have prevented the occurrence.

[Corrective Actions]{.underline}. Changes to design processes, work
instructions, workmanship practices, training, inspections, tests,
procedures, specifications, drawings, tools, equipment, facilities,
resources, or material that result in preventing, minimizing, or
limiting the potential for recurrence of a mishap.

[Direct Cost of Mishap or Close Call (for the purpose of mishap
classification)]{.underline}. The sum of the costs (the greater value of
actual or fair market value) of damaged property, destroyed property, or
mission failure, actual cost of repair or replacement, labor (actual
value of replacement or repair hours for internal and
external/contracted labor), cost of the lost commodity (e.g., the cost
of the fluid that was lost from a ruptured pressure vessel), as well as
resultant costs such as environmental decontamination, property cleanup,
and restoration, or the estimate of these costs.

[Endorsing Official]{.underline}. The Chief/OSMA, AMD, CHMO,
Procurement, or other official who reviews the signed mishap report and
provides a signed written endorsement, comments (when applicable), and a
recommendation as to whether the mishap report shall be approved or
rejected.

[Event]{.underline}. A real-time occurrence describing one discrete
action, typically an error, failure, or malfunction. Examples: pipe
broke, power lost, lightning struck, and person opened valve.

[Event and Causal Factor Tree]{.underline}. A graphic representation of
the mishap or close call that shows the event (accident) at the top of
the tree, depicts the logical sequence of events, illustrates all causal
factor(s) (including condition\[s\] and failed barrier\[s\]) necessary
and sufficient for the mishap or close call occurrence, and depicts the
root cause(s) at the bottom of the tree.

[Executive Summary]{.underline}. A very top-level summary of the
circumstances of a mishap that includes who, what, when, where, and why,
including a description of the proximate cause(s) and root cause(s).

[Ex Officio]{.underline}. An individual authorized to participate in all
investigation proceedings and tasked to assure that the investigation is
conducted in conformance with NASA policy and this NPR.

[Finding]{.underline}. A conclusion, positive or negative, based on
facts established during the investigation by the investigating
authority (i.e., cause, contributing factor, and observation).

[First Aid]{.underline}. Refer to OSHA definition in 29 CFR 1904.7.

[Final Mishap Investigation Report]{.underline}. The signed mishap
investigation report with the endorsements and comments attached.

[Flight Hardware]{.underline}. Any hardware that is flown on or is a
part of an aircraft, experimental flight vehicle, satellite, lighter
than air vehicles, unoccupied aerial vehicle, or space transportation
system.

[Flight Software]{.underline}. Any software that is flown on or is a
part of an aircraft, experimental flight vehicle, satellite, lighter
than air vehicles, unoccupied aerial vehicle, or space transportation
system.

[High Visibility (Mishaps or Close Calls)]{.underline}. Those particular
mishaps or close calls, regardless of the amount of property damage or
personnel injury, that the Administrator, Chief/OSMA, CD, AA/OIA, or the
Center SMA director judges to possess a high degree of programmatic
impact or public, media, or political interest including, but not
limited to, mishaps and close calls that impact flight hardware, flight
software, or completion of critical mission milestones.

[Hull Loss]{.underline}. An aircraft damaged to the extent that it is
not economically feasible to repair it. This includes aircraft that are
destroyed and aircraft that are missing.

[Human Factors Mishap Investigator]{.underline}. An investigator with
expertise in human factors engineering and mishap causation who has the
primary responsibility to assist in the collection and analysis of data,
determine how human factors caused or contributed to the mishap or close
call, evaluate relevant human error and determine its root cause(s), and
generate recommendations that eliminate or reduce the occurrence of the
error or minimize the negative effects of the error to prevent the
recurrence of the mishap.

[Incident]{.underline}. An occurrence of a mishap or close call.

[Investigating Authority]{.underline}. The individual mishap
investigator, mishap investigation team, or mishap investigation board
authorized to conduct an investigation for NASA. This includes the
mishap investigation board chairperson, voting members, and ex officio
but does not include the advisors and consultants.

[Lessons Learned]{.underline}. The written description of knowledge or
understanding that is gained by experience, whether positive (such as a
successful test or mission), or negative (such as a mishap or failure).

[Lost Time Injury/Illness]{.underline}. A nonfatal traumatic injury that
causes any loss of time from work beyond the day or shift it occurred;
or a nonfatal nontraumatic illness/disease that causes disability at any
time.

[Mishap Investigation Board (MIB)]{.underline}. A NASA-sponsored board
that:

a\. Is appointed for a Type A mishap, Type B mishap, high-visibility
mishap, or high-visibility close call.

b\. Requires concurrence from the Chief/OSMA and the Chief Engineer on
membership.

c\. Consists of an odd number of Federal employees (including the
chairperson) where the majority of the members are independent from the
operation or activity in which the mishap occurred.

d\. Has a minimum of five voting members for Type A mishaps and three
voting members for Type B mishaps.

e\. Includes a safety officer and a human factors mishap investigator.
For all Type A mishaps involving injury, illness, or fatality, also
includes an occupational health physician (or flight surgeon for
aircraft-related mishaps) as a member.

f\. Is tasked to investigate the mishap or close call and generate the
mishap report per the requirements specified in this NPR.

[Mishap Investigation Team (MIT)]{.underline}. A NASA-sponsored team
that:

a\. Is appointed by the CD or AA/OIA, or designee, for a Type C mishap,
Type D mishap, or close call.

b\. Does not require concurrence from the Chief/OSMA or the Chief
Engineer on team membership.

c\. Consists of an odd number of Federal employees (including the
chairperson) where the majority of the members are independent from the
operation or activity in which the mishap occurred. (The actual number
of members is chosen at the discretion of the appointing official.)

d\. Includes a safety officer and a human factors mishap investigator as
members.

e\. Is tasked to investigate the mishap or close call and generate the
mishap report per the requirements specified in this NPR.

[Mishap Investigator (MI)]{.underline}. A Federal employee who has
expertise and experience in mishap or close call investigation; has
knowledge of human error analysis in mishaps; serves as the sole
investigator for a Type C mishap, Type D mishap, or close call; and is
tasked to investigate the mishap or close call and generate the mishap
report per this NPR.

[Mishap Preparedness and Contingency Plans]{.underline}. Pre-approved
documents outlining timely organizational activities and
responsibilities that must be accomplished in response to emergency,
catastrophic, or potential (but not likely) events encompassing
injuries, loss of life, property damage, or mission failure.

[Mission Failure]{.underline}. A mishap of whatever intrinsic severity
that, in the judgment of the MDAA, program/project manager, or the
Chief/OSMA, prevents the achievement of primary NASA mission objectives
as described in the mission operations report or equivalent document.

[NASA Contractor or Grantee Mishap or Close Call]{.underline}. Any
mishap or close call that a NASA contractor/grantee is required to
report or investigate due to the provisions of its contract.

[NASA Mishap]{.underline}. An unplanned event that results in at least
one of the following:

a\. Injury to non-NASA personnel, caused by NASA operations.

b\. Damage to public or private property (including foreign property),
caused by NASA operations or NASA-funded development or research
projects.

c\. Occupational injury or occupational illness to NASA personnel.

d\. NASA mission failure before the scheduled completion of the planned
primary mission.

e\. Destruction of, or damage to, NASA property except for a malfunction
or failure of component parts that are normally subject to fair wear and
tear and have a fixed useful life that is less than the fixed useful
life of the complete system or unit of equipment, provided that the
following are true: 1) there was adequate preventative maintenance; and
2) the malfunction or failure was the only damage and the sole action is
to replace or repair that component.

[NASA Operation]{.underline}. Any activity or process that is under NASA
direct control or includes major NASA involvement.

[NTSB Serious Injury]{.underline}. Any injury resulting from an aircraft
mishap in which any one or more of the following apply:

a\. Requires hospitalization for more than 48 hours, commencing within 7
days from the date the injury was received.

b\. Results in a fracture of any bone (except simple fractures of
fingers, toes, or nose).

c\. Causes severe hemorrhages or nerve, muscle, or tendon damage.

d\. Involves any internal organ.

e\. Involves second- or third-degree burns, or any burns affecting more
than 5 percent of the body surface.

[Observation]{.underline}. A factor, event, or circumstance identified
during the investigation that did not contribute to the mishap or close
call, but, if left uncorrected, has the potential to cause a mishap or
increase the severity of a mishap; or a factor, event, or circumstance
that is positive and should be noted.

[Organizational Factor]{.underline}. Any operational or management
structural entity that exerts control over the system at any stage in
its life cycle, including, but not limited to, the system\'s concept
development, design, fabrication, test, maintenance, operation, and
disposal. Examples: resource management (budget, staff, training);
policy (content, implementation, verification); and management
decisions.

[OSHA Final Mishap Summary]{.underline}. A report (OSHA 301 Form: Injury
and Illness Incident Report, or an equivalent form) provided in
accordance with 29 CFR 1960.70 by NASA to the Office of Federal Agency
Programs for each mishap involving an OSHA recordable incident.

[Permanent Total Disability]{.underline}. Any nonfatal injury or
occupational illness that, in the opinion of competent medical
authority, permanently and totally incapacitates a person to the extent
that he or she cannot follow any gainful occupation and results in a
medical discharge or civilian equivalent.

[Permanent Partial Disability]{.underline}. Any injury or occupational
illness that does not result in a fatality or permanent total
disability, but, in the opinion of competent medical authority, results
in permanent impairment through loss of use of any part of the body,
with the following exceptions: loss of teeth, loss of fingernails or
toenails, loss of tip of fingers or tip of toe without bone involvement,
inguinal hernia (if it is repaired), disfigurements, or sprains or
strains that do not cause permanent limitation of motion.

[Property Damage]{.underline}. Damage to any type of government or
civilian property, including, but not limited to, flight hardware,
flight software, facilities, ground support equipment, and test
equipment.

[Proximate Cause]{.underline}. The event(s) that occurred, including any
condition(s) that existed immediately before the undesired outcome,
directly resulted in its occurrence and, if eliminated or modified,
would have prevented the undesired outcome. Also known as the direct
cause(s).

[Recommendation]{.underline}. An action developed by the investigating
authority to correct the cause or a deficiency identified during the
investigation.

[Responsible Organization]{.underline}. The organization responsible for
the activity, people, or operation/program where a mishap occurs or the
lowest level of organization where corrective action shall be
implemented.

[Root Cause]{.underline}. One of multiple factors (events, conditions,
that are organizational factors) that contributed to or created the
proximate cause and subsequent undesired outcome and, if eliminated or
modified, would have prevented the undesired outcome. Typically,
multiple root causes contribute to an undesired outcome.

> *[Rationale:]{.underline} The "or" in the definition confuses readers,
> and they think that if the event or condition is not an organizational
> factor (e.g. is a proximate or intermediate cause level) it could be
> considered a root cause.*

[Root Cause Analysis]{.underline}. A structured evaluation method that
identifies the root causes for an undesired outcome and the actions
adequate to prevent recurrence. Root cause analysis should continue
until organizational factors have been identified or until data are
exhausted.

[Serious Workplace Hazard]{.underline}. A condition, practice, method,
operation, or process that has a substantial probability that death or
serious physical harm could result and the employer did not know of its
existence or did not exercise reasonable diligence to control the
presence of the hazard.

[Substantial Damage]{.underline}. Damage or failure which adversely
affects the structural strength, performance, or flight characteristics
of the aircraft, and which would normally require major repair or
replacement of the affected component. Engine failure or damage limited
to an engine if only one engine fails or is damaged, bent fairings or
cowling, dented skin, small punctured holes in the skin or fabric,
ground damage to rotor or propeller blades, and damage to landing gear,
wheels, tires, flaps, engine accessories, brakes, or wingtips are not
considered "substantial damage" for the purpose of this part (from 49
CFR Part 830).

[Type A Mishap]{.underline}. A mishap resulting in one or more of the
following: (1) an occupational injury or illness resulting in a
fatality, a permanent total disability, or the hospitalization for
inpatient care of 3 or more people within 30 workdays of the mishap; (2)
a total direct cost of mission failure and property damage of \$1
million or more; (3) a crewed aircraft hull loss; (4) an occurrence of
an unexpected aircraft departure from controlled flight (except high
performance jet/test aircraft such as F-15, F-16, F/A-18, T-38, OV-10,
and T-34, when engaged in flight test activities).

[Type B Mishap]{.underline}. A mishap that caused an occupational injury
or illness that resulted in a permanent partial disability, the
hospitalization for inpatient care of 1-2 people within 30 workdays of
the mishap, or a total direct cost of mission failure and property
damage of at least \$250,000 but less than \$1,000,000.

[Type C Mishap]{.underline}. A mishap resulting in a nonfatal
occupational injury or illness that caused any days away from work,
restricted duty, or transfer to another job beyond the day or shift on
which it occurred, or a total direct cost of mission failure and
property damage of at least \$25,000 but less than \$250,000.

[Type D Mishap]{.underline}. A mishap that caused any nonfatal OSHA
recordable occupational injury and/or illness that does not meet the
definition of a Type C mishap, or a total direct cost of mission failure
and property damage of at least \$1,000 but less than \$25,000.

[Witness]{.underline}. A person who has information, evidence, or proof
about a mishap and provides his/her knowledge of the facts to the
investigating authority.

[Witness Statements]{.underline}. A verbal or written statement from a
witness that describes his/her account including a description of the
sequence of events, facts, conditions, and/or causes of the mishap.

**Appendix B. Acronyms**

AA/OIA Assistant Administrator, Office of Infrastructure and
Administration

AA/OPA Assistant Administrator, Office of Public Affairs

AMD Aircraft Management Division

CAP Corrective Action Plan

CD Center Director

CFR Code of Federal Regulations

Chief/OSMA Chief, Safety and Mission Assurance, Office of Safety and
Mission

Assurance

CHMO Chief Health and Medical Officer

DASHO Designated Agency Safety and Health Official

DoD Department of Defense

EAR Export Administration Regulations

FEEA Federal Employees Education and Assistance Fund

HQ Headquarters

IRIS Incident Reporting Information System

IRT Interim Response Team

ITAR International Traffic Arms Regulations

NAARS NASA Aviation Anomaly Reporting System

LLIS Lessons Learned Information System

MDAA Mission Directorate Associate Administrator

MI Mishap Investigator

MIB Mishap Investigation Board

MIT Mishap Investigation Team

NFAF NASA Family Assistance Fund

NFS NASA Federal Acquisition Regulation Supplement

NPD NASA Policy Directive

NPR NASA Procedural Requirements

NTSB National Transportation Safety Board

OIG Office of Inspector General

OJT On-the-Job Training

OPA Office of Public Affairs

Ops Operations

OSHA Occupational Safety and Health Administration

OSMA Office of Safety and Mission Assurance

OSMA/SARD Headquarters Office of Safety and Mission Assurance, Safety
and

> Assurance Requirements Division

OSPP Office of Security and Program Protection

PAO Public Affairs Office

PPE Personal Protective Equipment

SMA Safety and Mission Assurance

SMSR Safety and Mission Success Review

UAV Unmanned Aerial Vehicle

U.S.C. United States Code

**Appendix C. Mishap Investigation Notional Timeline**