DEPARTMENT OF THE AIR FORCE SMCR 800-17

Headquarters Space and Missile Systems Center

Los Angeles Air Force Base, CA 90245-4687

MISHAP/ANOMALY NOTIFICATION, REPORTING AND INVESTIGATION

1. Policy.

Establishes the SMC/CC's policies and procedures to expedite the notification, reporting and investigation of all mishaps involving SMC personnel, programs , and equipment; and to support the efficient planning, management and conduct of major mishap/anomaly investigations related to space and missile systems acquisition. The timely reporting of information to all levels regarding incidents which may attract international , national, USAF, or significant news media interest is essential in the day-to-day operations of this center. It is imperative that formal and informal (keeping the boss informed) practices be in effect for all mishaps and anomalies. (This policy in no way supersedes nor modifies AFI 91-204 (AFR 127-4), "Investigating and Reporting US Air Force Mishaps.)"

2. Background.

a. AFI 91-204 (AFR 127-4) establishes the general procedures for investigating and reporting of all Air Force mishaps. It identifies mishap class/category, explains required reports and establishes responsibilities, and the formation of mishap investigation boards. In addition, during system development and acquisition, major anomalies (which have the potential for significant schedule delays, cost overruns, or threaten program viability) may require special/independent investigations. However, experience has shown that the planning, data handling, analysis techniques and procedures for the conduct of the technical aspects of an investigation are often not well known, leading to significant delays in the expeditious completion of analyses and corrective actions.

b. Guidance Documents.

(1) Aerospace Report No. TOR-0090(5530-01)-1, "Mishap Investigation Procedures," 5 Feb 90. A guide document, derived from procedures and techniques applicable to space and missile systems.

(2) AFP 127-1, "US Air Force Guide to Mishap Investigation" (3 volumes), oriented to aircraft mishaps, but contains much detailed procedural and technical material generally applicable to any systematic investigation.

(3) SMCP 800-11, "Guide for Independent Readiness Reviews" lists procedures and checklists for Independent Readiness Reviews (IRRs), and the proceedings or results of any IRR pertinent to the event.

(4) Root Cause Analysis - A Diagnostic Failure Analysis Technique for Managers, Technical Report RF 75-2, US Army Missile Command, Redstone Arsenal, Alabama, 26 Mar 75.

(5) JCS Pub 6, Vol V, Operations Event/Incident Reports.

(6) AFI 91-202 (AFR 127-2), "The USAF Mishap Prevention Program".

(7) AFMCR 55-1, "AFMC Operations Center (OPREP-3)".

c. An experience base is resident with the SMC Health and Safety Division (SDZ).

3. Responsibilities and Procedures.

a. AFMC/CC has designated SMC/CC as the convening authority and investigating commander for mishap investigations of SMC programs. The central point for receiving information for this center is the SMC Command Center. It is the responsibility of each two-letter office to ensure that an operating instruction (OI) is in place; (1) to meet the reporting requirements of AFR 55-55 and AFI 91-204 (AFR 127-4) ; (2) Ensure the commander is kept apprised of the current situation during an incident/mishap and the investigative procedures following.

b. All SMC space mishaps will be investigated by both an Engineering Analysis Group and a separate safety Mishap Investigation Board. All SMC subordinate commanders and system program directors will follow these established procedures to expeditiously provide in-depth support to major mishap/anomaly investigations.

c. Each SMC System Program Director (SPD), Det/Lab Commander shall ensure that, for all major program operations (launch or major ground/lab operations) the timing of all data acquisition systems (video, telemetry, etc.) be synchronized.

d. Each SPD, Det/Lab Commander shall ensure that relevant contractor personnel are designated (or establish a plan for contractual coverage to designate contractor personnel) to plan, guide and manage contractor technical support to an investigation team.

e. To rapidly plan and manage investigation support tasks, program office and contractor personnel identified in 3.d. shall be knowledgeable of the provisions of AFI 91-204 (AFR 127-4), and of pertinent guidance documents identified in para 2.

f. Each SPD, Det/Lab Commander shall ensure the operating instruction identified in para 3.a. includes procedures for the proper handling and control of all data pertinent to the mishap/major anomaly for both new and on-going programs; and designates specific personnel by position.

g. SDZ shall provide the SMC Command Center an organizational personnel listing for notification purposes.

h. Deviation from the above schedule will require SMC/CC approval. Request for deviation will be coordinated through SD once the need for deviation has been determined.

4. Mishap Notification Responsibilities and Procedures.

a. In the event of a major mishap/anomaly the SPO/Det/Lab representative designated to report the event shall make notifications IAW the reporting procedures at Attachment 1. NOTE: It is imperative that the SMC Command Center be notified ASAP at DSN: 833-2353, or COM: (310) 363-2353.

b. SMC Command Center notifies SMC Command Section, SDZ, and AFMC Operations Center, DSN 787-5637, COM: (513) 257-5637 within one hour of notification.

c. SPD, Det/Lab Commander promptly notifies SMC/CC of details.

d. SMC/CC personally notifies AFMC/CC at DSN: 787-6033, COM: (513) 257-6033, Cellular: (513) 266-1463, or Staff Car Cellular: (513) 266-2362.

e. SDZ notifies AFMC/SE at DSN: 787-6618, COM: (513) 257-6618 and performs reporting procedures IAW AFI 91-204 chapter 4.

5. Convening the Investigative Groups.

a. When space systems or missiles of two or more MAJCOMS are involved, AFSA determines the investigating MAJCOM commander after consultation with the involved parties. AFSA/SEWS, DSN: 246-1364/1365, at the request of SMC/SD, will brief applicable procedures before initiating the investigation.

b. As convening authority, SMC/CC appoints the Engineering Analysis Group (EAG) and the Mishap Investigation Board (MIB). The EAG and MIB Presidents will normally be the senior member of each investigation and will determine the composition and expertise required to conduct thorough investigations. All members of each investigation should not have a personal interest in the investigation so that each one may act impartially. If a trained safety officer or specialist is not a member of the MIB, appoint one as a safety advisor.

6. Conducting the Investigations.

a. The EAG is chartered to determine the engineering facts leading to the cause of the mishap, using all available data from government or contractor sources. The EAG may consist of the following groups: Analysis Group, Core Vehicle Group, Launch Operations and Processing Group, Payload Group, Propulsion Group, Range Systems and Salvage Group, Support Group, and Fault Tree Group (Ishikawa "fishbones"). The Ishikawa "fishbones" technique has proven to be a powerful tool for linking together cause and effect scenarios at the systems level. The EAG President will determine the appropriate composition necessary to conduct a thorough investigation. Final results will be released to the MIB for use in conducting its investigation. All information collected during this investigation is fully releasable to industry and the public after coordination with SMC/CC and SMC/PA.

b. The MIB is chartered to conduct an independent formal investigation IAW AFI 91-204. This Board is typically a smaller group than the EAG. Its makeup may consist of approximately 3-7 members, i.e.: President, Vice President, Core Vehicle Engineer, Launch Operations and Processing Engineer Propulsion Engineer, Payload Engineer, Range Systems and Salvage Officer, Recorder, and Safety Advisor. The MIB membership may vary depending on the magnitude of the mishap. The MIB President will determine the appropriate expertise necessary to conduct a thorough review. Additional personnel may serve with the MIB in a supportive role. The MIB may attend all technical meetings, review the engineering analysis, collect testimony, deliberate on probable cause(s), and determine recommended corrective action. MIB members should be cautious not to ask questions at these meetings that may influence the direction or focus of the EAG. The final results will be released in Part II of the formal report. Information developed in this investigation is subject to the following constraints IAW AFI 91-204 (AFR 127-4):

(1) Any board conclusions or deliberations developed is privileged, limited-use information and releasable only to specified Air Force agencies. Privilege refers to information divulged by witnesses or developed by the MIB and will not be used for litigation purposes to include disciplinary, liability, or pecuniary recoupment.

(2) All individuals to include government, contractor, or civilians who are interviewed as witnesses are granted privilege to determine the truth of the cause(s) of the mishap.

7. Follow-on Action.

Follow-on action is IAW AFI 91-204, chapter 6 (AFR 127-4, chapter 14).

8. Supporting AFSPACECOM Investigations.

When AFSPACECOM requests technical assistance from an SMC program office, laboratory, or detachment to support an Engineering Analysis Group or Mishap Investigation Board, it is incumbent that each organization provide the necessary expertise required to conduct a thorough review.

EDWARD P. BARRY, JR.,

Lieutenant General, USAF

Commander Atch 1

MISHAP REPORTING CHECKLIST #1

ON-SITE REPRESENTATIVE AT A MILITARY LOCATION

_____________________________MISHAP/ACCIDENT/INCIDENT___________________________

______1. CONFIRM CORRECT CHECKLIST. RECORD DTG (Z): ___________

______2. RECORD INCIDENT:

DTG: _____________/______________________________________

LOCATION:_______________________________________________

DESCRIPTION OF EVENT:__________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

CURRENT STATUS:________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

______3. NOTIFY THE LOCAL COMMAND CENTER. PROVIDE THE INFORMATION IN STEP #2. REQUEST THE SMC/655ABS COMMAND CENTER AND AFMC OPERATIONS CENTER BE NOTIFIED ON THE OPREP-3 REPORT.

______4. NOTIFY YOUR PROGRAM DIRECTOR/SUPERVISOR. PROVIDE THE INFORMATION IN

STEP #2.

______5. MONITOR THE SITUATION AND PROVIDE STATUS UPDATES TO THE SMC/655 ABS COMMAND CENTER (DSN: 833-2353, COM: (310) 363-2353) AND YOUR PROGRAM DIRECTOR.

______6. CHECKLIST COMPLETE.

MISHAP REPORTING CHECKLIST #2

ON-SITE REPRESENTATIVE AT A NON-MILITARY LOCATION

_____________________________MISHAP/ACCIDENT/INCIDENT___________________________

______1. CONFIRM CORRECT CHECKLIST. RECORD DTG (Z): ___________

______2. RECORD INCIDENT:

DTG: _____________/______________________________________

LOCATION:_______________________________________________

DESCRIPTION OF EVENT:__________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

CURRENT STATUS:________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

______3. NOTIFY THE SMC/655 ABS COMMAND CENTER (DSN: 833-2353, COM: (310) 363-2353). PROVIDE THE INFORMATION IN STEP #2. REQUEST THE AFMC OPERATIONS CENTER BE NOTIFIED ON THE OPREP-3 REPORT.

______4. NOTIFY YOUR PROGRAM DIRECTOR/SUPERVISOR. PROVIDE THE INFORMATION IN

STEP #2.

______5. MONITOR THE SITUATION AND PROVIDE STATUS UPDATES TO THE SMC/655 ABS

COMMAND CENTER (DSN: 833-2353, COM: (310) 363-2353) AND YOUR PROGRAM DIRECTOR.

______6. CHECKLIST COMPLETE

MISHAP REPORTING CHECKLIST #3

NO ON-SITE REPRESENTATIVE AT A MILITARY/NON-MILITARY INSTALLATION

_____________________________MISHAP/ACCIDENT/INCIDENT___________________________

______1. CONFIRM CORRECT CHECKLIST. RECORD DTG (Z): ___________

***NOTE***

THE NOTIFICATION WILL EITHER BE MADE BY THE LOCAL COMMAND CENTER THROUGH OPREP-3 REPORTING CHANNELS TO THE SMC/655 ABS COMMAND CENTER OR THE PROGRAM DIRECTOR/SUPERVISOR WILL RECEIVE NOTIFICATION FROM THE INSTALLATION BY A TELEPHONE MESSAGE.

______2. PROGRAM DIRECTOR/SUPERVISOR:

______A. RECORD INCIDENT:

DTG: /

POC (NAME):

LOCATION:

PHONE:

DESCRIPTION OF EVENT:__________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

CURRENT STATUS:_______________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

______B. NOTIFY THE SMC/655 ABS COMMAND CENTER (DSN: 833-2353, COM: (310) 363- 2353). PROVIDE THE INFORMATION IN STEP #2A FOR OPREP-3 REPORTING. REQUEST THE AFMC OPERATIONS CENTER BE NOTIFIED ON THE OPREP-3 REPORT.

______C. MONITOR THE SITUATION AND PROVIDE STATUS UPDATES TO THE SMC/655 ABS COMMAND CENTER AND YOUR 2 LETTER DIRECTOR/SUPERVISOR.

______3. CHECKLIST COMPLETE.