Mishap Investigation

Mishap investigations allow NASA to understand the root cause of incidents and make adjustments to prevent recurrence. NASA conducts mishap investigations in accordance with NASA Procedural Requirements for Mishap Reporting, Investigating, and Recordkeeping (NPR 8621.1), which describes the procedure for reporting, investigating and documenting mishaps, close calls and previously unidentified workplace hazards to prevent similar occurrences in the future.

Mishap Investigation News

Mishap Program Highlights 2024 Milestones and Improvements

February 12, 2025

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

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Improving Mishap Investigations for Human Spaceflight

November 05, 2018

After each of NASA’s major mishaps — Apollo 1, Challenger and Columbia — the agency investigated the mishap and applied findings to future flights. As spaceflight became safer with the implementation of the lessons learned, mishap investigations also improved from each experience. With NASA preparing to fly three new crewed space vehicles in the coming years, clear understanding of the Mishap Investigation process with regards to Human Spaceflight and the underlying authorities and legal landscape of these investigations becomes paramount.

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People

Mike Masters

Mishap Investigation Program Executive

Learn more about Mishap Investigation Program Executive Mike Masters.

Points of Contact

For details on contacting a Mishap Investigation Point of Contact (PoC) for your location, click below.

Find Your PoC

Learning

Launch SATERN

SATERN Courses

Course Title	Course Number	Buttons
Completing the Investigation and Mishap Report	SMA-002-09	SMA-002-09 Details
Introduction to Human Factors in Mishap and Close Call Investigation	SMA-001-07	SMA-001-07 Details
Mishap Investigation Board (MIB) Chair Training	SMA-002-13	SMA-002-13 Details
Mishap Investigation Roles and Responsibilities	SMA-002-08	SMA-002-08 Details
NASA Human Factors in Mishap Investigation	SMA-002-15	SMA-002-15 Details
NASAHFACS Overview	SMA-HQ-WBT-227	SMA-HQ-WBT-227 Details
NASA Interim Response Team Training	SMA-002-11	SMA-002-11 Details
Overview of Mishap Investigations	SMA-002-07	SMA-002-07 Details
Root Cause Analysis	SMA-002-10	SMA-002-10 Details

Instructor-Led Courses

NASA Root Cause Analysis SMA-SAFE-OSMA-4003

This course provides training on Root Cause Analysis methodology that can be used in both general problem solving and Mishap and Close Call Investigation. It allows students to gain hands-on experience differentiating between events and conditions, identifying cause and effect relationships, discriminating between barriers and controls, constructing a timeline, and constructing Event and Causal Factor Trees. Examples and exercises will be provided from NASA and other government agencies.

SMA-SAFE-OSMA-4003 Details Launch SATERN

NASAHFACS Training and Certification SMA-SAFE-OSMA-4009

This three-day certification covers the concepts and information necessary to perform Human Factors analyses. It covers how to code Human Factors and mishaps, contribute to the agency database, and use the Human Factors Analysis and Classification System (HFACS) proactively.

*****You must complete the following prerequisite course before registering for this course*****

NASAHFACS OVERVIEW (SMA-HQ-WBT-227)

SMA-SAFE-OSMA-4009 Details Launch SATERN

Policy and Guidance

NASA

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

This policy provides requirements to report, investigate and document mishaps, close calls and previously unidentified serious workplace hazards to prevent recurrence of similar accidents.

See NPR 8621.1

NASA Mishap Information System

The NASA Mishap Information System (NMIS) is a custom-developed system for capturing mishaps, close calls and hazards, as required in NPR 8621.1, NASA Procedural Requirements for Mishap and Close Call Reporting, Investigating, and Recordkeeping. For further information or a demonstration, contact the Mishap Investigation Program Executive.

Mishap Preparedness and Contingency Plan Software

The Mishap Preparedness and Contingency Plan (MPCP) software is designed to assist NASA programs and projects in developing Contingency Plans required under NPR 8621.1, NASA Procedural Requirements for Mishap and Close Call Reporting, Investigating, and Recordkeeping. Program and project required inputs relating to mission success, pre-declares, hardware, hazards and key process phases are captured in a structured format with the final product generated in Microsoft Word. For further information or a demonstration, contact the Mishap Investigation Program Executive.

NASA Cause Analysis Tool

The NASA Cause Analysis Tool (NCAT) is a custom-developed web application used to collaborate on root cause analyses (RCA). NCAT will support the full mishap investigation process as defined in NPR 8621.1, but also makes root cause analysis techniques more accessible for smaller mishap investigations and other use cases, such as assessments. For further information or a demonstration, contact the Mishap Investigation Program Executive.

Flight Safety Office Interactive Tools

The Johnson Space Center Safety and Mission Assurance Flight Safety Office developed a suite of interactive tools to communicate significant safety mishaps and risks in human spaceflight. The tools are intended to raise awareness of past incidents and lessons learned to prevent future mishaps and make missions safer.

Frequently Asked Questions

Who owns NPR 8621.1, NASA Procedural Requirements for Mishap and Close Call Reporting, Investigating, and Recordkeeping?

The Office of Safety and Mission Assurance at NASA Headquarters, specifically the NASA mishap program executive, is the owner of this policy. The Mishap Investigation Support Office at the NASA Safety Center provides administrative, technical and analytical assistance to Mishap Investigation Boards and to the NASA mishap program executive.
Who owns the training and tools for Mishap Investigation?

The Office of Safety and Mission Assurance at NASA Headquarters owns the training and tools.
Who implements the training for Mishap Investigation?

The Office of Safety and Mission Assurance, with support from the NASA Safety Center, implements training. Supervisors, Safety and Mission Assurance directors, and safety managers should ensure there are sufficient personnel at their sites with the required training. “Introduction to Mishap Investigations” in SATERN is required for at least one board member and the ex-officio.
Is course work all it takes to be a “trained” investigator?

No, but it doesn’t hurt. Having served or participated on a Mishap Investigation Board and having a thorough understanding of the NPR 8621.1 also is beneficial.
Who manages Mishap Investigation Boards?

The chair appointed to the mishap investigation manages the board.
During an investigation, can you interview someone more than one time?

Yes. As the investigation progresses, additional facts may warrant revisiting some key witnesses.
Can interviews be recorded?

Yes. The witness must be made aware that he or she is being recorded and asked for consent. NPR 8621.1, Section 3.8 provides additional details on witness statements and confidentiality.
Is it permissible to ask about a person’s medical history?

Yes, it is permissible to ask about a person’s medical history, but this information cannot be released.
Should direct quotes from an interviewee be included in the mishap report?

No. Direct quotes could compromise the confidentiality of the witness.
Who can attend deliberations of a Mishap Investigation Board (MIB)?

Participation is limited to NASA employees. All board members listed in the appointment letter should participate in deliberations. In addition, consultants do not participate in deliberations (vote on findings) (NPR 8621.1, paragraph 1.4.19 a).
Can a contractor support the creation of the Events and Causal Factor Tree (E&CFT)?

In general, no. The E&CFT should be a product of the MIB, which is comprised of NASA personnel.
Why is a weather event classified separately from earthquakes, volcanoes, etc.?

Earthquakes and volcanoes generally are considered to be of a higher severity and of less common frequency than normal or expected seasonal changes in weather.
Under what circumstances would upper management change a mishap classification?

Property damage estimates could change and require a change in classification. Also, a high-visibility incident may require an increase.
For injuries, why are workdays, not weekdays counted?

This requirement comes from the Occupational Safety and Health Administration listed in 1904.7(b)(3)(iv): “How do I count weekends, holidays, or other days the employee would not have worked anyway? You must count the number of calendar days the employee was unable to work as a result of the injury or illness, regardless of whether or not the employee was scheduled to work on those day(s). Weekend days, holidays, vacation days or other days off are included in the total number of days recorded if the employee would not have been able to work on those days because of a work-related injury or illness.”
Does the Office of Safety and Mission Assurance (OSMA) verify contractor participation in mishap investigations for a given contract?

There is an ongoing effort to include such language in contracts for NASA contractors.
Does the NASA Safety Center (NSC) approve the final mishap report?

No. Approval of final mishap reports and products is the responsibility of the appointing and endorsing officials.
What is the notification process for mishaps? Can it be informal?

The notification for all classifications of mishaps and close calls is described in NPR 8621.1, Chapter 3, Initial Response to a Mishap or Close Call.
Do all advisors have to be used in an investigation? Do they all sign the report?

If an advisor is listed in the appointment letter, his or her signature also must appear on the final report. Additional support personnel should be acknowledged.
Is there any plan to have more than three Mishap Investigation specialists for the agency?

This is being discussed, and the Mishap Investigation Support Office and the agency mishap manager welcome involvement and comment from the mishap community.
Do all levels of mishaps (Types A, B, C, D, Close Call) require the same techniques or tools during the investigation, e.g., Root Cause Analysis and E&CFT?

The same techniques and tools can be used for all mishaps. Root Cause Analysis is necessary for all mishaps, but not all elements of the analysis are required to be in the final report.
Do all mishap investigations find a root cause?

No, but they need to attempt to determine if any exist.
Can a contributing factor have a root cause?

Yes, but it is a root cause for the contributing factor and should be listed as such.
Who approves Center Mishap Preparedness and Contingency Plans?

The chief, OSMA approves Center Mishap Preparedness and Contingency Plans.

Important Links

Federal Aviation Administration: Information on aircraft, airports, air traffic, data and research, licenses and certificates, regulations and policies, and training and testing

NASA Mishap Information System: Custom-developed system for capturing mishaps, close calls and hazards

National Transportation Safety Board: News and events and information on safety advocacy, investigations, disaster assistance and legal

Significant Incidents and Close Calls in Human Spaceflight: Dynamic inforgraphic from Johnson Space Center

U.S. Chemical Safety Board

Investigation information, recommendations, media materials and videos

Print Version

Classification Level	Property Damage	Injury
Type A Mishap	Total direct cost of mission failure and property damage of $2,000,000 or more, or Crewed aircraft hull loss, or Unexpected aircraft departure from controlled flight for all aircraft except when departure from controlled flight has been pre-briefed (e.g., upset recovery training, high AOA envelope testing, aerobatics, or OCF for training) or mitigated through the flight test process inherent at each Center.	Occupational injury or illness resulting in A fatality, or A permanent total disability.
Type B Mishap	Total direct cost of mission failure and property damage of at least $500,000, but less than $2,000,000.	Occupational injury or illness resulting in A permanent partial disability, or Hospitalization for inpatient care of three or more people within 30 workdays of the mishap.
Type C Mishap	Total direct cost of mission failure and property damage of at least $50,000, but less than $500,000.	Nonfatal OSHA-recordable occupational injury or illness resulting in days away from work, or restricted duty, or transfer to another job beyond the day or shift on which it occurred. or Hospitalization for inpatient care of one or two people within 30 workdays of the mishap.
Type D Mishap	Total direct cost of mission failure and property damage of at least $20,000, but less than $50,000.	Nonfatal OSHA-recordable occupational injury or illness that does not meet the definition of a Type C mishap.
Close Call	Total direct cost of mission failure and property damage of less than $20,000, but event has the mishap potential using a worst case estimate.	Injury requiring first aid or less, but event has the mishap potential using a worst case estimate.

Print Version

Every NASA center has a Mishap Investigation Point of Contact (PoC). For more information, contact the PoC at your center.

Lacelia Williams-Hudson Hernan Posada

Name
Office of Safety and Mission Assurance
Mike Masters
Ames Research Center
David King*
Aleah Rohr Daniel
Armstrong Flight Research Center
Nick Kiriokos*
Leah Brooks
Shawn Kern
Roosevelt Jones
Glenn Research Center
Scott Mahnke*
Eli McDivitt
Goddard Space Flight Center
Darren Bergan*
Lisa Cutler
Headquarters Operations
Christopher J. Warren*
Kellien Peritz
Claire Seasoltz
Jet Propulsion Laboratory
Tony Likovich*
Tiffany Lee
Cesar Romano
Johnson Space Center
Robert Southers*
Lacelia Williams-Hudson
Katrina Glenn
Katherine Johnson Independent Verification and Validation Facility
David Sheldon*
Kennedy Space Center
Lester Jean*
Brad Frizzell
Langley Research Center
Alesia Miller*
Christopher Swanson (Aviation)
Marshall Space Flight Center
Geoffrey Card*
Todd Waldrop
Michoud Assembly Facility
David Howitt*
Yaisa Wilson
Stennis Space Center
Ronald Good*
Milford Olinger
Wallops Flight Facility
Logan Wright*
Peter Dell
Jason Rabon
White Sands Test Facility
Kurt Rathgeber*
Aviation Safety
Hernan Posada
Facility and Occupational Safety
Jose Caraballo
Launch Services Program
Christopher L. Guodace
Safety Culture/Human Factors
Tracy Dillinger
Isabel Hernandez

*Primary

Mishap Investigation