Source: This document taken from the Report of Apollo 204 Review Board

SUBJECT: Mission Failure Investigation Policy And Procedures

1. Purpose

This Instruction established the policy and procedure for investigating and documenting the causes of all major mission failures which occur in the conduct of NASA space and aeronautical activities.

2. Applicability

This Instruction is applicable to NASA Headquarters and field installations.

3. Definition

For the purpose of this Instruction, the following term shall apply:

In general, a failure is defind as not achieving a major mission objective.

4. Policy

a. It is NASA policy to investigate and document the causes of all major mission failures which occur in the conduct of its space and aeronautical activities and to take appropriate corrective actions as a result of the findings and recommendations.

b. The Deputy Administrator may conduct independent investigations of major failures in addition to those investigations required of the Officials-in-Charge of Headquarters Program Offices as set forth in paragraph 5a.

5. Procedures

a. Officials-in-Charge of Headquarters Program Offices are responsible, within their assigned areas, for:

• Informing promptly the Deputy Administrator of each major failure and apprising him of the nature of the failure, status of investigations, and corrective of other actions which are or will be taken.
  
• Determining the causes or probable causes of all failures, taking corrective of other actions, and submitting written reports of such determinations and actions to the Deputy Administrator.

(1)Establish a (name of project) Review Board, comprised of appropriate NASA officials;

(2)Define the specific responsibilities of each Board, encompassing such tasks as:

• Reviewing the findings, determinations and corrective or other actions which have been developed by contractors, field installations and the Officials-in-Charge of cognizant Headquarters Program Office and presenting the Board's conclusions as to their adequacy to the Deputy Administrator.

• Reviewing the findings during the course of investigations with cognizant field installation and Headquarters officials.

• Recommending such additional steps (for example additional tests) as are considered desirable, to determine the technical and operational causes or probable causes of failure, and to obtain evidence of nontechnical contributing factors.

• Developing recommendations for corrective and other actions, based on all information available to the Board.

• Documenting findings, determinations and recommendations for corrective or other actions and submitting such documentation to the Deputy Administrator.

6. Cancellation

NASA Management Manual Instruction 4-1-7 (T.S. 760), March 24, 1964.

(Robert J. Seamans, Jr.) Deputy Administrator

Updated February 3, 2003
Steve Garber, NASA History Web Curator
For further information E-mail histinfo@hq.nasa.gov