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Ames Procedural
Requirements

APR 1700.1

Last Revised: 10/7/2008

COMPLIANCE IS MANDATORY


Ames Health and Safety Manual

Chapter 4 - Mishap Reporting and Investigating

Table of Contents

4.1 Overview
4.2 Authority
4.3 References
4.4 Terms and Definitions
4.5 Description of Mishaps and Close Calls
4.6 Mishap Classification Levels and Investigation Types
4.7 Responsibilites
4.8 Mishap Investigation Process
4.9 Corrective Action


4.1 Overview

In accordance with NPR 8621.1, "NASA Procedural Requirements for Mishap and Close Call Reporting, Investigating, and Record Keeping.Ó This Chapter establishes the Ames Research Center (ARC) procedural requirements for reporting and investigating mishaps and close calls. The purpose of mishap investigation is to determine the cause(s) and implement effective corrective actions in order to prevent recurrence of similar mishaps at Ames.

This directive applies to all Ames Employees, Ames contractors and grantees as specified in their contracts or grants; and to other organizations (i.e., commercial partners, other Federal agencies, international parties, and Ames tenants) as specified and described in written operating agreements.

This Chapter does not apply to investigations concerning civil, criminal, or administrative culpability or legal liability. The safety investigative process shall not be used to direct or justify disciplinary action.

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4.2 Authority

NPD 8621.1, NASA Mishap Reporting and Investigating Policy.
NPR 8715.3, NASA Safety Manual

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4.3 References

NPR 8621.1, NASA Procedural Requirements for Mishap and Close Call Reporting, Investigating, and Record keeping

29 CFR Part 1904, Recording and Reporting Occupational Injuries and Illnesses.

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4.4 Terms and Definitions

Ames Safety Office Occupational Safety, Health and Medical Services Division, Ames organization responsible for investigating, reporting and recording mishaps.

Appointing Official 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.

Contributing Factor 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 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). The sum of the costs (the grater 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 fluid that was lost from a ruptured pressure vessel, as well as resultant costs such as environmental decontamination, property cleanup, and restoration, or the best official estimate of these costs.

Ex Officio An individual authorized to participate in all investigation proceedings and tasked to assure that the investigation is conducted in conformance with NASA policy and NPR 8621.1. IRIS Incident Reporting Information System (http://nasa.ex3host.com/IRIS/)

IRIS Incident Reporting Information System. (http://nasa.ex3host.com/IRIS/)

Mishap Investigation Team (MIT) A NASA-sponsored team that:

  1. Is appointed by the Center Director, Director of Safety and Mission Assurance, Chief of Safety, or designee, for a Type B mishap, Type C mishap, Type D mishap, or close call investigation.
  2. 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 chosen is determined by the appointing official.)
  3. Includes a safety officer and a human factors mishap investigator as members.
  4. Is tasked to investigate the mishap or close call and generate the mishap report per the requirements specified in NPR 8621.1.

Mishap Investigator (MI) 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.

Note: A single mishap investigator may be assigned to a Type B mishap based upon mishap severity and with NASA headquarters approval.

Proximate Cause 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).

Root Cause One of multiple factors (events, conditions, or 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.

SATERN System for Administration, Training, and Educational Resources for NASA https://satern.nasa.gov

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4.5 Description of Mishaps and Close Calls

4.5.1 A NASA Mishap is an unplanned event that results in at least one of the following:

  1. Injury to non-NASA personnel, caused by NASA operations.
  2. Damage to public or private property (including foreign property), caused by NASA operations or NASA-funded development or research projects.
  3. Occupational injury or occupational illness to NASA personnel.
  4. NASA mission failure before the scheduled completion of the planned primary mission.
  5. 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.

4.5.2 Close Call description and mishap classification levels are listed in figure 1.

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4.6 Mishap Classification Levels and Investigation Types

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.

Figure 1 Mishap Classification Levels and Investigation Types

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4.7 Responsibilities

4.7.1 Employees

  1. If witness to, or involved in a NASA mishap or close call, employees shall immediately notify emergency response, if required. From and internal NASA Ames phone dial 911, from a pay phone or cell phone dial (650) 604-5555. For non-emergency mishap and close call reporting contact the Ames Safety Office at 4-5602.
  2. Notify the Ames Safety Office after emergency response (if required) has been initiated.

4.7.2 Program/Project Managers

  1. Immediately contact the Ames Safety Office at 4-5602 when a mishap or close call occurs (after emergency response has been initiated). Activate Program/Project mishap preparedness plan.
  2. Develop and maintain a program/project mishap preparedness and contingency plan per NPR:8621.1, NASA Procedural Requirements for Mishap and Close Call Reporting, Investigating, and Recordkeeping.
  3. Submit a Quick Incident report on the IRIS web site (http://nasa.ex3host.com/IRIS/) or complete the NASA Mishap Report form NF1627 and submit it to the Ames Safety Office within 24 hours or complete the online quick incident report.
  4. Provide funding and support for investigations within program jurisdiction or involving program hardware and facilities.
  5. Determine the direct cost of the mishap or close call.
  6. Generate corrective action plan to address any findings and/or recommendations identified by the mishap investigation. Corrective action plan shall include a listing of identified findings and recommendations along with planned actions to correct the identified deficiency, an estimated completion date for each action, and the name of the manager responsible for ensuring the action is completed.

4.7.3 Supervisors

  1. Immediately contact the Ames Safety Office at 4-5602 when a mishap or close call occurs (after emergency response has been initiated).
  2. Ensure that any injured person immediately reports to the Ames Health Unit or that emergency response is initiated.
  3. Identify potential witnesses and get statements from them.
  4. Secure the mishap scene and protect it from being disturbed.
  5. Submit a Quick Incident report on the IRIS web site (http://nasa.ex3host.com/IRIS/) or NASA Mishap Report form NF1627 and submit it to the Ames Safety Office within 24 hours or complete the online quick incident report.
  6. Initiate drug testing after a mishap, if the mishap results in a fatality or personal injury requiring immediate hospitalization or damage estimated to be in excess of $10,000 to government or private property.
  7. Support the mishap investigation as necessary.
  8. Determine the direct cost of the mishap or close call.
  9. Generate corrective action plan to address any findings and/or recommendations identified by the mishap investigation. Corrective action plan shall include a listing of identified findings and recommendations along with planned actions to correct the identified deficiency, an estimated completion date for each action, and the name of the manager responsible for ensuring the action is completed.

4.7.4 Organization Directors

  1. Ensure that the policies and procedures for reporting, investigating and documenting mishaps and taking corrective action are implemented and that employees are familiar with the roles and responsibilities as documented within this Chapter.
  2. Provide support to Ames mishap investigations such as personnel, engineering support, testing, or data analysis.
  3. Review mishap reports and corrective action plans for mishaps that occur in your directorate.
  4. Ensure corrective action plans for mishaps in your Directorate are implemented in a timely manner.
  5. Provide funding and support for mishap investigations or enabling activities.

4.7.5 Center Director

  1. Implement mishap reporting, investigation, and recordkeeping requirements for all projects, programs, and activities at Ames.
  2. Provide funding and support for mishap investigations or enabling activities.
  3. Serve as appointing official for mishaps occurring at Ames or involving offsite Center support contractors.
  4. Generate official memorandum in support of the mishap investigation and reporting process.
  1. Mishap Investigation Board appointment letter
  2. Request for corrective action
  3. Report endorsement letter
  1. Notify the Administrator within 24 hours of learning the instance of any NASA Type A or Type B mishap
  2. Determine the investigation timeframe and assign a completion date.

4.7.6 Ames Safety Office

  1. Serve as the CenterŐs focal point for receiving all oral and written mishap and close call reports.
  2. Assist the appointing official to determine the mishap classification level.
  3. Notify Ames senior management and NASA Headquarters Within one hour of the occurrence of a Type A mishap, Type B mishap, high-visibility mishap, or high-visibility close call, per NPR 8621.1.
  4. Within eight (8) hours after the death of any employee from a work-related incident or the in-patient hospitalization of three or more employees as a result of a work-related incident, report the fatality/multiple hospitalization by telephone or in person to the Area Office of the Occupational Safety and Health Administration (OSHA), U.S. Department of Labor as required per 29 CFR Part 1904.39.
  5. Deploy an interim response team to collect written statements, take photos, and preserve evidence.
  6. Ensure the protection of personnel from residual hazard material prior to entry into the mishap site, if required.
  7. Impound all appropriate data, records, equipment, and facilities involved in the mishap.
  8. Verify that appropriate measures have been taken to secure the mishap scene, to protect personnel from hazards and to preserve evidence.
  9. Ensure that all mishaps and close call information is entered in the Incident Reporting Information System (IRIS) within 24 hours.
  10. Help the appointing official determine the type of investigation required and who will be involved in the investigation of a mishap.
  11. Maintain list of personnel trained in mishap investigations.
  12. Review and approve mishap reports and corrective action plans.
  13. Verify that corrective actions have been effectively implemented.
  14. Perform trend analysis and other statistical analyses of mishap and close call data.

4.7.7 Mishap Investigator(s)

  1. All members of the assigned mishap investigation team will be required to successfully complete the web-based NASA introduction to mishap investigation training course (available on SATERN).
  2. At least one member of the assigned mishap investigation team will be required to successfully complete web-based NASA introduction to mishap investigation training course (available on SATERN) as well as the NASA Root Cause Analysis instructor led training course.
  3. Conduct all activities in accordance with this procedure and NPR 8621.1
  4. Ensure the control and safety of the mishap area and nearby occupants, visitors, etc.
  5. Obtain and analyze whatever evidence, facts, and opinions considered relevant.
  6. Conduct tests and any other activity deemed appropriate.
  7. Interview witnesses and receive statements from witnesses.
  8. Impound property, equipment, and records as considered necessary (consistent with the agreements with the international partners and contractors)
  9. Determine the proximate cause(s), root cause(s), and contributing factors relating to the mishap.
  10. Develop recommendations to prevent similar mishaps.
  11. Provide a final written report within NASA timelines, that will conform to all requirements referenced in NPR 8621.1
  12. Submit the completed signed mishap report to the appointing official within the timeframe identified by the appointing official in the appointment letter.

4.7.8 Ames Protective Services

  1. a. Ensure that evidence and relevant information are preserved for the safety investigation.
  2. b. Assist safety investigators in securing mishap scenes.

4.7.9 Office of the Chief Counsel

  1. a. Provide legal support to mishap investigation teams and boards.
  2. b. Review mishap information or reports prior to public release.

4.7.10 Contracting Officers Technical Representative (COTR)

Ensure that ARC contractors understand and follow all NASA and ARC contract requirements for mishap investigation and reporting.

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4.8 Mishap Investigation Process

All Ames mishaps will be investigated per NPR:8621.1, NASA Procedural Requirements for Mishap and Close Call Reporting, Investigating, and Recordkeeping

Figure 2: NASA Mishap Investigation Process

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4.9 Corrective Action

Responsible organizations will develop and submit a corrective action plan within 15 work days from being tasked. Corrective action plan shall include the following:

All findings and generated by mishap investigations will be entered into the Ames Safety Accountability Program (ASAP) Hazard Reporting system and tracked through closure.

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