NPR Revisions Include Changes to NASA Mishap Classifications and Investigation Boards

NPR Revisions Include Changes to NASA Mishap Classifications and Investigation Boards

NPR 8621.1B

NASA Procedural Requirements 8621.1B for Mishap and Close Call Reporting, Investigating and Recordkeeping was updated through administrative changes that took effect on July 15, 2013. The changes come as a result of a coordinated effort between all NASA centers.

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WHAT'S NEW

Four updates were made to the NPR:

1. NASA’s mishap classification levels were updated. Specifically, the classification criteria for Type B and D mishaps were redefined:

Type B Injury

Before: Occupational injury or illness that resulted in a permanent partial disability or hospitalization for inpatient care of one or more people within 30 workdays of the mishap.

Now: Occupational injury or illness that resulted in a permanent partial disability or hospitalization for inpatient care of three or more people within 30 workdays of the mishap.

Type D Property Damage

Before: Total direct cost of mission failure and property damage equal to or greater than $1,000 but less than $50,000.

Now: Total direct cost of mission failure and property damage equal to or greater than $20,000 but less than $50,000.

Consequently, the definitions of Type C mishaps and Close Calls have changed as well. (See Figure 1 for full descriptions of Type A, Type B, Type C and Type D mishaps and Close Calls.)

WHY IT MATTERS

Prior to this change, 70 percent of Type B mishaps involved the hospitalization of one person; no recent Type B mishaps involved three or more people. This change will dramatically decrease the number of Type B mishaps.

RATIONALE

Changing the classification criteria for NASA mishaps will reduce the time and resources dedicated to investigating relatively minor injuries or damages and resolving issues that led to the mishaps. It also aligns NASA classifications with the Department of Defense (DOD), which gives NASA an opportunity to use the DOD as a benchmark.

Although many incidents that would have been mishaps will now be considered Close Calls, it is still important to treat these incidents seriously because they indicate a risk of future mishaps.


2. The revised NPR recommends the use of a mishap investigation specialist from the Office of Safety and Mission Assurance’s Mishap Investigation Support Office (MISO) as the ex officio for Type A and Type B mishaps and for high visibility incidents. (See Section 1.4.12.d.)

WHY IT MATTERS

Previously, policy did not require a MISO specialist to serve on the board of Type A and B mishap investigations; it was just recommended. Now, a MISO specialist should be on the board, unless one is unavailable at that time.

RATIONALE

This change improves the efficiency and quality of investigations. Because the specialist sees all investigation reports, he or she has agency-wide knowledge of best practices and lessons learned and can share that information with the board.


3. NASA Mishap Investigation Training is now required every 5 years as opposed to every 3 years for the entire Mishap Investigation Board (MIB), including the ex officio, advisors and consultants. (See Sections 4.3.3, 4.4.4 and 4.5.2.)

WHY IT MATTERS

The new requirement affects all future members of MIBs.

RATIONALE

Reducing the frequency of required training leads to a reduction in travel expenses without diminishing performance.


4.The revised NPR makes a clear distinction between flight and ground operations. Now, only mishaps that occur from the time someone boards the aircraft (or activates an unmanned aircraft) with the intention of flight to the time that person deboards the aircraft (or deactivates an unmanned aircraft) after flight are considered flight operations mishaps. (See Appendix A.)

WHY IT MATTERS

Previously, aircraft mishaps did not distinguish between flight and ground operations.

RATIONALE

Flight mishaps and ground operation mishaps are very different. This clarification allows the data to be separated, making it more meaningful.


This NPR currently is being rewritten. NPR 8621.1C will enter NODIS soon for center and agency review.

TAKE ACTION

These changes affect anyone involved with reporting or investigating a NASA mishap or close call. Review the policy to ensure compliance with all changes and requirements. When reporting a mishap or close call, account for the new mishap classification system and qualifications for flight and ground operations. All affected board members should adjust any scheduled mishap training to account for the longer duration between required refresher courses.

Have questions regarding any of the current updates or the status of the upcoming revisions? Contact Gerry Schumann.