21 and hazards. The mishap plan should also establish a location for securing data and physical evidence, as well as methods of maintaining a chain of custody, logging evidence, controlling access, and other means to safeguard integrity of data and physical evidence. Hazardous debris, such as unexploded ordnance, should be stored in a separate, secured facility, with access restricted to appropriately trained and certified personnel. As noted in AC 437.73-1, to assist in determining root cause and corrective actions or preventative measures, the FAA recommends collecting, cataloging, and retaining all data related to the mishap. This data can include, but is not limited to, the following:
Analysis and test results, Change control documents, Contracts, Correspondence, Debris, Design drawings and specifications, Environmental factors (workplace environment, weather conditions), Equipment history logs, Inspection and Maintenance records, Policies, procedures, and work logs Training documentation, Vehicle close out photographs, Vehicle telemetry, Vendor manuals, Voice and video recordings, and Witness statements.
9.5.1 Treatment of Debris.
In general, an operator should not move or disturb debris without prior approval from the investigative authority, except to remove injured or trapped persons, to protect the wreckage from further damage, or to protect the public from injury. Prior to moving debris, the debris should be fully documented (measured, photographed, etc.), and location recorded for investigative purposes to the extent possible without hindering efforts to protect public safety in accordance with § 450.173(d)(4).
Note: As noted in the Streamlined Launch and Reentry Licensing Requirements Notice of Proposed Rulemaking, the FAA considers debris to be a physical record of the mishap’s occurrence. Section 450.219(b) requires operators to maintain records, including debris, associated with a mishap until the FAA advises the licensee that the records need not be retained.
9.5.2 Documenting Physical Evidence.
When possible, the operator should systematically document, collect, protect, and preserve physical evidence. Operators should collect evidence in a manner that permits future evaluation of how and why the mishap occurred. The mishap plan should consider the following:
9.5.2.1 Site Documentation – Using sketches and maps to document the overall scene and position of debris. Geotagged photos are especially beneficial when documenting a site and debris distribution.
9.5.2.2 Cataloging Debris – Document individual debris components, including physical location (coordinates), debris dimensions, weight, and general description of the item. Operators should document this information in a centralized evidence log.
9.5.2.3 Photographing Debris – Photography is a valuable tool for documenting the overall mishap site, location of individual debris relative to the overall site, configuration, and condition. When photographing debris, the FAA recommends using GPS-equipped cameras. Bring sufficient memory cards and at least one spare set of batteries. Rulers or items of a known physical size should be included in close-up pictures to show scale and perspective.
For each group of photographs, an overall photograph showing positions relative to a known point, such as a land feature, diagram reference point, or building should be included. A photograph log should be used to record the photograph number, content, type, and location. Location information could include either coordinates (latitude and longitude), or the direction and distance to a prominent feature, such as the launch pad or impact crater. See Table 3 of this AC.
Note: Refer to the “Initial Photography” section of FAA Order 8020.11D, as revised, for additional considerations when photographing a mishap site.
23 Table 3 – Sample Photo Log Photo # Content Type Location 001 Debris field Overview (O) 123.45N, 17.32W 002 Stage 1 skin fragment Close Up (C) NW, 150’
9.5.2.4 Debris Handling – An operator should thoroughly document debris before handling it. When handling debris, never try to fit pieces back together.
Touching fracture surfaces, especially to each other, destroys evidence of the fracture type. The type of fracture could be the only evidence of the vehicle’s failure mode.
Movement of debris due to emergency first responder activities should be recorded. Talk to first responders to determine what may have been moved and ask for any documentation (photographs or video) they may have documenting debris movement. Also, in the event debris was cut during rescue efforts, record all cuts.
Debris should only be handled by trained and qualified personnel having the proper personal protective equipment required based on known site hazards. Refer to FAA Order 8020.11, as revised, for more information on the handling of wreckage (debris) and precautions that should be taken into consideration.
9.5.2.5 Tagging Debris – The operator should tag and document all recovered debris. The operator should use tags with strings to identify parts and avoid tags with metal wires as they may damage the debris further. If containers are used to store debris, ensure they are soft compared to the debris being stored or that the debris is sufficiently protected (i.e. wrapped in bubble wrap). You can use plastic bags or bins for small pieces of metal and some composites. If debris is chemically contaminated, ensure storage containers and wrapping materials are compatible with chemical contamination (e.g., hypergols). When tagging debris, you should include the following:
Debris catalog number, Photo number(s), Part name or unique identifier, Part or serial number, if known, and Recovery location (Geotagged photos may eliminate this need).
9.5.2.6 Additional Documentation – Further considerations to ensure a mishap site is fully documented include:
24 Obtain names and contact information of critical personnel on-scene, Obtain photos or other documentation of the mishap site from first responders such as fire department, law enforcement, and rescue personnel, Collect contact information from all witnesses and first responders for interviews or statements, and Collect video evidence.
Note: See FAA Order 8020.11, as revised for additional considerations.
9.6 Implementing Agreements.
In accordance with § 450.147(a)(4), the operator is responsible for entering into agreements with government authorities and emergency response providers, as necessary, to satisfy the requirements of § 450.173. Section 450.173(d)(5) requires operators to implement agreements with governments and emergency responders as necessary to satisfy § 450.173. This can include, but is not limited to:
Emergency medical and fire services, Local law enforcement, Federal launch range/installation emergency response services, and Local city or county emergency operation centers.
Note: Section 450.173(d)(5) requires an operator to implement agreements with government authorities and emergency responders “as necessary” to satisfy the requirements of § 450.173. An operator that launches from a Federal launch or reentry site, or licensed launch or reentry site is not required to execute agreements with local authorities if their launch or reentry site use agreement, as required by § 450.147(a)(1), has the necessary coordination in place to satisfy the requirements of § 450.173.
25 10 MISHAP INVESTIGATION REQUIREMENTS.
Under § 450.173(e), in the event of a mishap, the operator must investigate the root cause of the mishap and report the investigation results to the FAA.
10.1 Investigation Procedures.
The operator’s mishap plan should clearly document the procedures for investigating the root cause of a mishap and for reporting results to the FAA. As noted earlier, in accordance with § 450.173(b), the mishap plan must clearly delineate responsibilities of personnel assigned to conduct an investigation and anyone retained to conduct, or participate in, any mishap investigation. The mishap plan procedures should include, but are not limited to, the following:
Composition of the mishap investigation team, to include investigation team lead and minimum team members. These procedures should include provisions to expand the team membership based on additional expertise to support the investigation, as required.
Coordination with industry and government stakeholders to ensure the proper level of support for the investigation.
Documented method for determining root cause of the event, including what happened, how it happened, and why it happened. Root cause should extend beyond the technical cause of the event and include organizational root causes (e.g., insufficient training for employees, decreased safety culture, overlooked employee safety concerns, etc.).
Documented description of the investigative review process, including the review and approval of data packages supporting root cause and corrective action determinations. Procedures should also address the recording of any dissenting opinions.
Detail/explanation on how applicable supporting analysis will be performed
(i.e., methodology, tools, criteria or standards, etc.).
Provide for periodic updates to the FAA during the course of an investigation, on a schedule as mutually agreed upon between the operator and the FAA.
10.2 Root Cause Analysis.
The root cause is the fundamental reason or underlying cause that, if eliminated, would mean the mishap would not have occurred. The root cause differs from the proximate or direct cause, which is the immediate cause of the problem leading to a mishap. For example, a loose fuel line, resulting in a fuel leak would be the proximate cause of an inflight fire. However, the failure of a technician to torque and safety wire the fuel line b-nut may be a root cause of the problem.
10.2.1 A mishap may have multiple root causes. To identify a root cause, it is necessary to look beyond the direct cause, to perform a root cause analysis and understand potential organizational deficiencies as well the technical issue. In the example provided in paragraph 10.2 of this AC, a root cause analysis may determine that the technician did not follow existing procedures. Similarly, it may determine that the procedures were inadequate, or that the organization did not employ the standard of independent verification or quality assurance to check the technician’s work after installation.
Factors contributing to the problem could include inadequate training, personnel changes, or a simple distraction during a critical step.
10.2.2 A root cause analysis should include the following steps at a minimum.
Scope of the Investigation – an operator should identify the bounds of the investigation including timeframe of the occurrence, systems that had the ability to contribute to the event, and any accepted risk items or issues related to those systems.
Event Timeline – an operator should identify a general timeline of the operations leading up to and during the occurrence.
Root Cause Analysis Process – an operator should define a process for its investigation. This should include the investigation methodology (e.g., fault tree, fishbone, video analysis, etc.), integration between engineering investigation teams, presentation of determinations made by engineering investigation teams to the investigation board, and board member voting or decision-making processes.
Causal Factor Process – an operator should have an iterative process to continue investigating areas of concerns until finding a true root cause (e.g., the “5-whys”).
This most typically ends at an organizational root cause linked to design, operations, or both.
Identify and Implement Preventive Measures – an operator should identify and implement preventive measures on future and existing vehicles to ensure that the mishap does not recur such that public safety is not impacted.
Preventative Measures Follow-Up – an operator’s plan should include a process for following up to verify the implementation and effectiveness of preventative measures. This follow-up should ensure preventative measures remain adequate and did not result in or introduce an unintended consequence.
10.3 Reporting Investigation Results to the FAA.
The purpose of a mishap investigation report is to clearly and concisely document and convey the results of the investigation. The final, signed mishap investigation report must be submitted for FAA review, in accordance with § 450.173(e)(2). The FAA recommends use of the NASA mishap report format, as documented in NASA Procedural Requirements (NPR 8621.1, as revised), which includes the following sections:
Section 1: Signature pages, list of consultants, and executive summary.
Section 2: Narrative description and facts (what, when, where, and how).
27 Section 3: Type of data gathered and data analysis (timeline; analytical techniques used; fault tree, or similar graphical representation).
Section 4: Findings (and evidence on which those findings are based, proximate and root causes, and contributing factors).
Section 5: Recommendations (preventative measures and corrective actions to avoid a recurrence of the event).
Section 6: Minority report, if applicable.
Note: The final mishap report should contain all applicable document markings (Proprietary, International Traffic in Arms Regulations (ITAR)) necessary to restrict its release in accordance with 14 CFR 413.9, as appropriate.
Note: The executive summary should include a publically releasable description of the mishap, findings, and preventative measures or corrective actions.
10.4 FAA and National Transportation Safety Board (NTSB) Investigations.
Based on the severity and consequences of the event, the FAA or NTSB may initiate an investigation to determine root or probable cause and make recommendations for avoiding a recurrence of the event. In the event of a Federal investigation, the operator will be a participant/party to the investigation. However, the operator may conduct a concurrent investigation in accordance with their approved mishap plan provided it does not interfere with the Federal investigation.
Note: In accordance with § 450.209(a), a licensee must allow access by, and cooperate with, Federal officers or employees or other individuals authorized by the FAA to observe any of its activities, or any of its contractors’ or subcontractors’ activities, associated with the conduct of a licensed launch or reentry. In addition, per § 450.13, issuance of a vehicle operator license does not relieve a licensee of its obligation to comply with all applicable requirements of law or regulation that may apply to its activities.
10.5 Press Conferences and Press Releases.
All operator press conferences and press releases related to a commercial space transportation mishap should be coordinated with the FAA. Press conference coordination should take place with enough advanced notification to allow for FAA participation as required. Press releases should be coordinated with the FAA’s Office of Communication prior to release.
10.6 Release of Investigative Information.
In the event of a Federal investigation, the release of investigative information should be coordinated with the lead investigative agency.
10.6.1 FAA Investigations.
In the event of an FAA investigation, the FAA’s Office of Communications is responsible for the release of information to the public. All operator press releases should be coordinated with the FAA’s Office of Communication in coordination with the Office of Commercial Space Transportation prior to release.
10.6.2 NTSB Investigations.
In the event of an NTSB investigation, the release of information to the public must be coordinated with the NTSB Investigator in Charge (IIC) in accordance with 49 CFR § 831.13(c). Refer to 49 CFR § 831.13, Provision and dissemination of investigative information, for more details.
11 PREVENTATIVE MEASURES.
In accordance with § 450.173(f), an operator must identify and implement preventative measures for avoiding the recurrence of a mishap, following the determination of root cause and contributing factors. Corrective actions should not only address technical root causes, but also any organizational root causes. Unless otherwise approved by the FAA, in accordance with § 450.173(f), an operator must implement preventative measures prior to the next flight. Operators often identify several preventative measures. For example, in the event of a mishap involving an in-flight fire, preventative measures could include revising existing procedures to include inspection steps to verify the installation of safety wire on all fuel line b-nuts or requiring additional training for personnel. The mishap plan should take into consideration the following:
Process for identifying and approving preventative measures and corrective actions, Process for validating that proposed preventative measures and corrective actions are correct, complete, and feasible, Process and timeline for implementing preventative measures and corrective actions, and Process for implementing and verifying preventative measures and corrective actions are effective.
29 12 MISHAP RECORDS.
12.1 Records Retention.
Under 14 CFR § 450.173(g), operators are required to maintain all records associated with a mishap in accordance with § 450.219(b). Section 450.219(b) requires an operator to preserve all records related to an event that meets paragraph (1) through (5), or (8) of the definition of mishap, as defined in § 401.7. An operator must retain and make available to Federal officials for inspection or copying all records covered by § 450.219(b) until completion of any Federal investigation and notification from the FAA that the records need not be retained.
Note: Licensed launch site operators and experimental permittees are required to retain records in accordance with §§ 420.61 and 437.87, respectively.
12.2 Debris Disposal.
Although the FAA considers debris to be a physical record of a mishap occurrence, the FAA does not expect operators to retain debris for more than three years following the completion of a mishap investigation. Section 450.219(b) requires operators to maintain records, including debris, associated with a mishap until the FAA advises the licensee that the records need not be retained. Hazardous debris must be disposed of in accordance with applicable safety and environmental requirements.
12.3 Incorporating Recordkeeping into the Mishap Plan.
The FAA recommends incorporating the records requirements of § 450.219 into the mishap plan to ensure all required records and physical evidence are properly maintained. For any mishap that occurs that meets paragraphs (1) through (5), and (8) of § 401.7, an operator must preserve all records related to the event in accordance with § 450.219(b). Operators shall retain the records until any Federal investigation is complete and the FAA advises the licensee that the records can be disposed.
13 APPLICATION REQUIREMENTS.
Under § 450.173(h), an applicant must submit a plan or other written means satisfying these requirements of this section. A plan developed in accordance with this AC satisfies the requirements of 14 CFR § 450.173.
Note: In addition to a mishap plan, per § 450.189(e), an operator must have general emergency procedures that apply to any emergencies not covered by the mishap plan of § 450.173 that may create a hazard to the public.
Appendix A A-1 Appendix A. Sample Mishap Notification Checklist Template.
[Insert position responsible for completing tasks] Mishap Notification Checklist In the event of a mishap… Notify the FAA Washington Operation Center
1. Involving a fatality or serious injury Immediately Phone: (202) 267-3333 Toll-free: (800) 322-3804 Email: 9-awa-ash-woc@faa.gov Fax: (202) 267-5289 2. Not involving a fatality or serious injury Within 24-hours Submit a preliminary written report including the following information, as applicable, to… FAA Office of Commercial Space Transportation
(i) Date and time of the mishap;
(ii) Description of the mishap and sequence of events leading to the mishap, to the extent known;
(iii) Intended and actual location of the launch or reentry or other landing on Earth;
(iv) Hazardous debris impact points, including those outside a planned landing site or designated hazard area;
(v) Identification of the vehicle;
(vi) Identification of any payload;
(vii) Number and general description of any fatalities or injuries;
(viii) Description and estimated costs of any property damage;
(ix) Identification of hazardous materials, as defined in § 401.7 of this chapter, involved in the event, whether on the vehicle, any payload, or on the ground;
(x) Action taken by any person to contain the consequences of the event;
(xi) Weather conditions at the time of the event; and
(xii) Potential consequences for other similar vehicles, systems, or operations.
Within five days of the mishap to the assigned FAA Mishap Response Coordinator.
800 Independence Avenue SW Washington, DC 20591 202-267-7793 202-267-5450 (fax) Note: The lack of information known should not delay the immediate notification.
OMB Control Number: 2120-0746 (Expiration Date: 08/31/2023)
FAA Form 1320-73 (06-2020)
Advisory Circular Feedback Form
If you find an error in this AC, have recommendations for improving it, or have suggestions for new items/subjects to be added, you may let us know by (1) emailing this form to ASTApplications@faa.gov, or (2) faxing it to (202) 267-5450.
Subject: (insert AC title/number here) Date: Click here to enter text.
Please check all appropriate line items:
☐ An error (procedural or typographical) has been noted in paragraph Click here to enter text.
on page Click here to enter text..
☐ Recommend paragraph Click here to enter text. on page Click here to enter text. be changed as follows:
Click here to enter text.
☐ In a future change to this AC, please cover the following subject:
(Briefly describe what you want added.)
Click here to enter text.
☐ Other comments:
Click here to enter text.
☐ I would like to discuss the above. Please contact me.
Submitted by: Date:
Paperwork Reduction Act Burden Statement: A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a currently valid OMB Control Number. The OMB Control Number for this information collection is 2120-0746. Public reporting for this collection of information is estimated to be approximately 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. All responses to this collection of information are voluntary to obtain or retain benefits per 14 CFR 77. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Federal Aviation Administration, 10101 Hillwood Parkway, Fort Worth, TX 76177-1524.