MSFC NASA MWI 8621 1 REV D-2009 MISHAP AND CLOSE CALL REPORTING AND INVESTIGATION PROGRAM《灾害及幸免于难的报告和调查程序》.pdf

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1、CHECK THE MASTER LIST at https:/repository.msfc.nasa.gov/directives/directives.htm VERIFY THAT THIS IS THE CORRECT VERSION BEFORE USE MWI 8621.1 REVISION D EFFECTIVE DATE: February 3, 2009 EXPIRATION DATE: February 3, 2014 MARSHALL WORK INSTRUCTION QD01 MISHAP AND CLOSE CALL REPORTING AND INVESTIGAT

2、ION PROGRAM Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Marshall Work Instruction QD01 Mishap and Close Call Reporting and MWI 8621.1 Revision: D Investigation Program Date: February 3, 2009 Page 2 of 49 CHECK THE MASTER LIST at https:/repository

3、.msfc.nasa.gov/directives/directives.htm VERIFY THAT THIS IS THE CORRECT VERSION BEFORE USE DOCUMENT HISTORY LOG Status (Baseline/ Revision/ Canceled) Document Revision Effective Date Description Baseline 3/27/00 Revision A 8/22/01 Document rewritten in its entirety. Revision B 10/29/2004 Document r

4、evised to meet NPR 8621.1 latest rev and reformatted per HQ requirements review. Revision C 4/11/2008 Major re-write. Changed document name to better match NPR 8621.1. Revised 2. Applicability statement to address the applicability of this directive to the Michoud Assembly Facility. Revised to meet

5、NPR 8621.1B and expand on/clarify MSFC specific requirements to better define roles and responsibilities. Added role for an IRIS representative for each organization. Grammar and editorial changes made throughout document. Revision D 2/3/2009 Added Table of Contents. Rearranged several sections to m

6、ake flow better. Added items in 6.23 to be closed in IRIS before Mishap can be closed by ISB. Split Appendix Z into 4 appendices to better identify examples. Minor editorial and grammar changes throughout MWI for clarity. Provided by IHSNot for ResaleNo reproduction or networking permitted without l

7、icense from IHS-,-,-Marshall Work Instruction QD01 Mishap and Close Call Reporting and MWI 8621.1 Revision: D Investigation Program Date: February 3, 2009 Page 3 of 49 CHECK THE MASTER LIST at https:/repository.msfc.nasa.gov/directives/directives.htm VERIFY THAT THIS IS THE CORRECT VERSION BEFORE US

8、E TABLE OF CONTENTS PARAGRAPH PAGE P.1 Purpose. 5 P.2 Applicability. 5 P.3 Applicable Documents 5 P.4 References 6 P.5 Definitions 6 Document Contents 6. Instructions 12 6.1 Pre-Mishap Planning . 12 6.2 Activating Emergency Response 14 6.3 Notification to ISB of an Incident . 14 6.4 Notification to

9、Center Director of an Incident 15 6.5 Notification to NASA HQ of an Incident . 16 6.6 Notification to OSHA of an Incident 17 6.7 Notification by Contractor of an Incident. 17 6.8 Notification to MSFC Employees of an Incident . 17 6.9 Mishap/Incident Classification . 18 6.10 Entering Initial Incident

10、 Notification Information Into IRIS 18 6.11 OSHA 300 Log . 19 6.12 Post-Incident Drug Testing Process 19 6.13 Securing the Incident Site. 20 6.14 Appointing the Investigating Authority . 21 6.15 Conducting an Incident Investigation. 24 6.16 Typical Incident Investigation Timeline 26 6.17 Investigati

11、on Reports. 27 6.18 Investigation Status. 30 6.19 Corrective Action Plan (CAP) 31 6.20 CAP Implementation 32 6.21 Assess Effectiveness of the CAP Implementation . 33 6.22 Process to Close an Incident Case File 33 6.23 Closing the Incident Case File in IRIS 34 6.24 Distributing the Final Investigatio

12、n Report Information . 34 6.25 Release of Investigation Information to News Media 34 6.26 Mishap Involving Criminal Activity, Weather, or Aircraft 35 6.27 MSFCs MAF . 35 7. Notes 35 8. Safety Precautions and Warning Notes. 35 9. Records 36 Provided by IHSNot for ResaleNo reproduction or networking p

13、ermitted without license from IHS-,-,-Marshall Work Instruction QD01 Mishap and Close Call Reporting and MWI 8621.1 Revision: D Investigation Program Date: February 3, 2009 Page 4 of 49 CHECK THE MASTER LIST at https:/repository.msfc.nasa.gov/directives/directives.htm VERIFY THAT THIS IS THE CORRECT

14、 VERSION BEFORE USE 10. Personnel Training and Certification. 36 11. Flow Diagram 38 12. Cancellation 38 Appendix A, Mishap Investigation Level 39 Appendix B, Mishap Notification Call List. 40 Appendix C, Example Mishap Investigation Form . 42 Appendix D, Mishap Investigation Status Report 44 Append

15、ix Z -1, Example Statement of Witness . 45 Appendix Z-2, Example Investigator/Investigation Team Assignment Memorandum . 46 Appendix Z-3, Example Mishap Investigator/Investigation Team Mishap Report . 47 Appendix Z-4, Example Notification to NASA Headquarters 49 Provided by IHSNot for ResaleNo repro

16、duction or networking permitted without license from IHS-,-,-Marshall Work Instruction QD01 Mishap and Close Call Reporting and MWI 8621.1 Revision: D Investigation Program Date: February 3, 2009 Page 5 of 49 CHECK THE MASTER LIST at https:/repository.msfc.nasa.gov/directives/directives.htm VERIFY T

17、HAT THIS IS THE CORRECT VERSION BEFORE USE 1. PURPOSE To provide Marshall Space Flight Center (MSFC) requirements for reporting, investigating, and documenting NASA/MSFC mishaps, close calls, and previously unidentified serious workplace hazards to determine the root cause(s) in order to develop and

18、 implement corrective actions to prevent recurrence in accordance with NASA, MSFC, and Occupational Safety and Health Administration (OSHA) requirements and policies. 2. APPLICABILITY This MWI applies to the personnel, programs, projects, and activities at MSFC and MSFCs Michoud Assembly Facility (M

19、AF), including contractors and resident agencies to the extent specified in their respective contracts or agreements. (“Contractors,” for purposes of this paragraph, include contractors, grantees, Cooperative Agreement recipients, Space Act Agreement partners, or other agreement parties.) 3. APPLICA

20、BLE DOCUMENTS 3.1 29 CFR Part 1904, “Recording and Reporting Occupational Injuries and Illnesses” 3.2 The Privacy Act of 1974, as amended, 5 U.S.C. 552a 3.3 NFS 1852.223-70, “Safety and Health” 3.4 NPR 1441.1, “NASA Records Retention Schedules (NRRS)” 3.5 NPR 3792.1, “Plan for a Drug-Free Workplace”

21、 3.6 NPR 8621.1, “NASA Procedural Requirements for Mishap and Close Call Reporting, Investigating, and Recordkeeping” 3.7 NPR 7120.5, “NASA Space Flight Program and Project Management Requirements” 3.8 NPR 8715.3, “NASA General Safety Program Requirements” 3.9 MPD 1380.1, “Release of Information to

22、News and Information Media” 3.10 MPR 1040.3, “MSFC Emergency Plan” 3.11 MPR 3410.1, “Training” 3.12 MPR 3810.1, “MSFC Management of Workers Compensation Injuries and Illnesses” 3.13 Marshall Engineers and Scientists Association (MESA) Agreement (see URL: http:/ohc.msfc.nasa.gov/eso/labor/mesa/mesa_a

23、greement_all.html#19) Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Marshall Work Instruction QD01 Mishap and Close Call Reporting and MWI 8621.1 Revision: D Investigation Program Date: February 3, 2009 Page 6 of 49 CHECK THE MASTER LIST at https:/

24、repository.msfc.nasa.gov/directives/directives.htm VERIFY THAT THIS IS THE CORRECT VERSION BEFORE USE 4. REFERENCES None 5. DEFINITIONS The list below addresses the most commonly used mishap and close call terms. For a complete list of terms, see NPR 8621.1. 5.1 Aircraft Mishap. An aircraft mishap i

25、s an occurrence associated with the operation of an aircraft, which takes place between the time any person boards the aircraft with the intention of flight and all such persons have disembarked, and in which any person suffers a fatality or serious injury, or in which the aircraft receives substant

26、ial damage. 5.2 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 final investigation report. See Appendix

27、 A for a list of Appointing Officials. 5.3 Cause. An event or condition that results in an effect and can shape or influences the outcome. 5.4 Close Call. An event in which there is no injury or only minor injury requiring first aid and/or no equipment/property damage or minor equipment/property dam

28、age (less than $1,000), which possesses a potential to cause a mishap. 5.5 Contributing Factor. An event or condition that may have contributed to and/or increased the probability of an undesired outcome but, if eliminated or modified, would not by itself have prevented the occurrence. 5.6 Correctiv

29、e Action Plan (CAP). A plan developed to address each finding of the mishap investigation with a level of corrective action that emphases correcting the proximate and root cause(s) of the mishap. 5.7 CAP Closure Statement. A final statement made by the appointing official that documents that all cor

30、rective actions have been completed and the CAP is closed. 5.8 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

31、, minimizing, or limiting the potential for recurrence of a mishap. Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Marshall Work Instruction QD01 Mishap and Close Call Reporting and MWI 8621.1 Revision: D Investigation Program Date: February 3, 2009

32、 Page 7 of 49 CHECK THE MASTER LIST at https:/repository.msfc.nasa.gov/directives/directives.htm VERIFY THAT THIS IS THE CORRECT VERSION BEFORE USE 5.9 Direct Cost of Mishap or Close Call (for the purpose of mishap classification). The sum of the costs (the greater value of actual or fair market val

33、ue) 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/contract labor), cost of the lost commodity (e.g., the cost of the fluid that was lost from a ruptured pressure vessel),

34、 as well as resultant costs such as environmental decontamination, property cleanup, and restoration, or the best official estimates of these costs. NOTE: Replacement costs are to be included, even if salvage/excess parts are available at little or no cost to NASA. If insurance or contractor compens

35、ation is available or provided, then the direct cost is to be calculated as if the compensation were not available or provided. The cost of mishap investigation is not to be included. 5.10 Endorsing Official. Officials who reviews the signed final investigation report and provides a signed written e

36、ndorsement, comments (when applicable), and a recommendation for approval or rejection of the final investigation report. See Appendix A for a list of Endorsing Officials. 5.11 Ex Officio Representative. An individual authorized to participate in all investigation proceedings and tasked to ensure th

37、at the investigation is conducted in conformance with NASA and MSFC requirements. 5.12 Event (as applied in this MWI). Something that has happened or occurred and has the potential to result in a mishap or close call. 5.13 First Aid. Any one-time treatment of minor scratches, cuts, burns, splinters,

38、 etc., which does not ordinarily require medical care, and any follow-up visit(s) for the purpose of observation. Such one-time treatment, and follow-up visit(s) for the purpose of observation, are considered first aid even though provided by a physician or registered professional. See 29 CFR 1904.7

39、(b)(5)(ii) for complete definition. 5.14 High-Visibility Incident (Mishap or Close Call). Those particular mishaps or close calls, regardless of the amount of property damage or personnel injury, that the NASA Administrator, NASA Chief/Office of Safety and Mission Assurance (OSMA), Center Director (

40、CD), Assistant Administrator, Office of Infrastructure and Administration (AA/OIA), or Center Safety a lesson that is significant (has real or assumed impact on operations); valid (is factually and technically correct); and applicable (identifies a specific design, process, or decision that reduces

41、or limits the potential for failures and mishaps); or reinforces a positive result. 5.25 Lost Workday Case (Lost-time Injury/Illness). A nonfatal traumatic injury that causes any loss of time from work beyond the day or shift it occurred; or a non-traumatic illness that causes disability at any time

42、. 5.26 Lost Workdays. The number of days (consecutive or not) after, but not including, the day of injury or illness during which the employee would have worked but could not do so; i.e., could not perform all or any part of his normal assignment during all or any part of the workday or shift becaus

43、e of the occupational injury or illness. Includes days away, restricted duty, or transfer to another job. Total number includes weekends and holidays occurring during the lost workday period. 5.27 Medical Treatment. The management and care of a patient to combat disease or disorder. Includes treatme

44、nt administered by a physician or by a registered professional under the standing orders of a physician. Medical treatment does not include visits to a physician for observation or counseling, diagnostic procedures such as X-rays and blood test including administration of prescription medications us

45、ed solely for diagnostic purposes or first aid treatment even though provided by a physician or registered professional personnel. 5.28 Mishap Investigation Board (MIB). A NASA-sponsored board that is appointed for a Type A, Type B, or high visibility mishap or close call; requires concurrence from

46、the Chief/OSMA and the Chief Engineer on membership; consists of an odd number of Federal employees where the majority of the members are independent from the mishap operation; includes a safety officer, human factors mishap investigator, and occupational health physician or industrial hygienist (for injury/illness/fatality) as members. 5.29 Mishap Investigation Team (MIT). A NASA-sponsored team that is appointed by the CD or AA/OIA, or designee for Type C, Type D mishap or close call; consists of an odd number of Federal employees with the majority of members in