Updates to Policy on Mishap and Close Call Reporting, Investigating and Recordkeeping Improve Investigation Process
Changes to NPR 8621.1, Mishap and Close Call Reporting, Investigating, and Recordkeeping went into effect on May 19, 2016. These updates build on 8621.1B With Change 7, which was released on July 15, 2013.
NPR 8621.1C includes more than 170 updates and changes. The following
are the three major highlights affecting personnel:
1. The document was reorganized to match the order of the steps in NASA’s mishap investigation process.
WHY IT MATTERS
Content throughout the NASA Procedural Requirements (NPR) has been rearranged and reworded to reflect the mishap investigation process. Also, Chapter 1, which summarized the requirements outlined in the rest of the document, was removed to avoid redundancy.
Members of Mishap Investigation Boards (MIBs) and others involved with the investigation process sometimes lacked a solid understanding of the timeline for when requirements should be addressed. This change more clearly defines the requirements of each stage of the investigation, so all personnel involved know what to do and what is coming next. Also, the roles of everyone involved in an investigation are easier to understand.
2. The endorsement process for mishap reports has changed — now, reports are given to the appointing and endorsing officials prior to the out-brief and endorsed during that meeting.
WHY IT MATTERS
With the new process, the purpose of the out-brief has changed. Previously, the appointing official and the endorsing officials did not receive the mishap report until the out-brief. During this meeting, members would review the report and begin to gather their questions or concerns, and the report often would not get endorsed until long after the 30-day deadline.
Speeding up the endorsement process will assist centers greatly with acting on Corrective Actions (CAs) and developing criteria for prevention of like mishaps.
3. The release process for mishap reports also has changed. Reports only will be released publicly if a request is submitted; however, MIBs will write the reports in a releasable manner so they are prepared for dissemination should they be requested.
WHY IT MATTERS
Reports will be released to the agency, but only made public upon request. MIBs now are responsible for writing the initial report so it could be released. As members of the MIB, public affairs and legal personnel can support the effort. Should the mishap involve technical content or proprietary information that prevents a report from being appropriate for public consumption, the board is expected to write a releasable executive summary.
Before this update, it could take between 100 and 200 days to move a mishap report through the public release process, and there was no guarantee it would ever be approved for the public. NASA centers did not receive the report until the process was complete, which delayed the implementation of CA plans at the center where the mishap occurred, and also delayed sharing the information with other centers that could learn from the incident to prevent a similar occurrence. Because reports no longer will be sent through this process, the release time for the centers will shorten, thereby ensuring CAs get implemented as soon as possible.
In addition, because MIBs will write the reports or executive summaries for public release, if a Freedom of Information Act request comes in, the length of time it will take to prepare the report for release will be much shorter, increasing NASA’s transparency.
Many other changes, including clarifications on training requirements, were made throughout the NPR. To learn the specifics of all the changes, review the NPR Requirements Tracking. This NPR will continue to be updated and revised, in particular, specific annexes such as those relating to aircraft, spacecraft and commercial space
Personnel in the Safety and Mission Assurance (SMA) community — specifically those involved with mishaps including Mishap Program Working Group members, safety professionals, program managers, mission directorates and SMA directors — need to review this revised document and become familiar with the updated requirements and their roles during an investigation. These personnel also should keep their management abreast of these changes and how they affect various jobs and the center as a whole.