NASA’s Mishap Program ended 2024 with an impressive roster of achievements, improvements and updated resources that the agencywide Mishap community can utilize. Highlights include:

1.  The latest version of NPR 8621.1, NASA Procedural Requirements for Mishap and Close Call Reporting, Investigating, and Recordkeeping, which expires in July, is nearing completion and release. A small team spent the year reviewing, updating and editing Version D of the NPR and gathering feedback from Mishap personnel to create the new Version E. The updated version includes streamlined resources for mishap and close call investigations across the agency. The new version is expected to enter NODIS review within the next few weeks.
   
2. To support real-time collaboration among Mishap personnel conducting Root Cause Analyses (RCA), the NASA Safety Center (NSC) developed a custom web-based application called the NASA Cause Analysis Tool (NCAT). It allows brainstorming, evidence management and the ability to explore and depict causal relationships. NCAT is especially useful for conducting smaller mishap investigations, which will help the agency collect and trend causal data. Teams can use the RCA process to evaluate any event, condition or situation where there’s a gap between desired versus actual performance.
   
3. The NASA Mishap Information System (NMIS)—NASA’s custom-developed software for capturing mishaps, close calls and hazards—underwent significant updates in 2024 to align with NCAT, incorporate upcoming NPR revisions and reflect the latest user and data quality requirements. The NMIS User Guide may be accessed on the NSC website or via SharePoint.
   
4. In conjunction with the NMIS updates, a new NMIS Mishap and Close Call Trends Dashboard was released that uses Power BI to provide stakeholders the latest data on mishap and close call trends in customizable reports. The information can be filtered and analyzed to suit users’ mishap reporting needs. A helpful link to this dashboard is located on the NMIS login screen.
   
5. New standardized Mishap Program forms were released for use by all agency Mishap personnel. These forms consolidated and replaced center-specific forms. New and updated forms include:
   • NF 1918           Mishap Warning Action Response (MWAR)
   • NF 1919           NASA Mishap Investigation Form
   • NF 1927           Mishap Investigation Evidence Log
   • NF 1928           Mishap Investigation Imagery Log
   • NF 1932           Mishap Investigation Status Report

     A complete list of mishap forms can be found on the Mishap Investigations page of the NSC website.

6. The NASA Mishap Investigation Handbook was extensively reviewed, condensed and updated to provide Mishap personnel with an easy-to-use reference for conducting their own mishap investigations. The handbook may be accessed on the NSC website or via SharePoint.
   
7. New training courses developed in 2024 included a condensed in-person RCA class. Additionally, NASA Interim Response Team Training (SMA-002-11) was updated and the new version is available now in SATERN.
   
8. Mishap Program Health Assessments are in progress across the agency to evaluate and improve each center’s Mishap processes.

If you have any questions about these resources, contact the NSC Help Desk.