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NASA-LLIS-1251
Lessons Learned – Failure to Report an Incident as a NASA Mishap
Year: 2001
Abstract: Description of Driving Event:
Early on Saturday, April 21, 2001, a pipe in the secondary water system failed in the basement of Building 8 at the NASA Goddard Space Flight Center. The primary asset damaged by the resulting flood was the NASA photo archive, located immediately below the location where the pipe failed. Although the incident was reported verbally and by e-mail to Goddard management, no formal NASA Mishap Report Form 1627 was filed until 6 weeks after the incident. The supervisors who were affected by the flood were unaware of their responsibility to file a written report. One supervisor who did attempt to write up the incident could not complete the report because of lack of information on the value of the damaged asset. The process for submitting the NASA Mishap Report Form 1627 is cumbersome and ill-defined. Most supervisors who do not have frequent experiences with mishaps and mishap reporting are unaware that they are responsible for the paperwork. The form also requires an assessment of the value of the damaged asset, which in this case could not be determined. Finally, the form is not available on-line at Goddard, but employees are directed to request a copy from the Safety and Environmental Branch.
Early on Saturday, April 21, 2001, a pipe in the secondary water system failed in the basement of Building 8 at the NASA Goddard Space Flight Center. The primary asset damaged by the resulting flood was the NASA photo archive, located immediately below the location where the pipe failed. Although the incident was reported verbally and by e-mail to Goddard management, no formal NASA Mishap Report Form 1627 was filed until 6 weeks after the incident. The supervisors who were affected by the flood were unaware of their responsibility to file a written report. One supervisor who did attempt to write up the incident could not complete the report because of lack of information on the value of the damaged asset. The process for submitting the NASA Mishap Report Form 1627 is cumbersome and ill-defined. Most supervisors who do not have frequent experiences with mishaps and mishap reporting are unaware that they are responsible for the paperwork. The form also requires an assessment of the value of the damaged asset, which in this case could not be determined. Finally, the form is not available on-line at Goddard, but employees are directed to request a copy from the Safety and Environmental Branch.
Subject: Administration/Organization
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| contributor author | NASA - National Aeronautics and Space Administration (NASA) | |
| date accessioned | 2017-09-04T18:22:30Z | |
| date available | 2017-09-04T18:22:30Z | |
| date copyright | 04/21/2001 | |
| date issued | 2001 | |
| identifier other | AGVEQCAAAAAAAAAA.pdf | |
| identifier uri | http://yse.yabesh.ir/std;jsery=autho162s7D8308/handle/yse/204895 | |
| description abstract | Description of Driving Event: Early on Saturday, April 21, 2001, a pipe in the secondary water system failed in the basement of Building 8 at the NASA Goddard Space Flight Center. The primary asset damaged by the resulting flood was the NASA photo archive, located immediately below the location where the pipe failed. Although the incident was reported verbally and by e-mail to Goddard management, no formal NASA Mishap Report Form 1627 was filed until 6 weeks after the incident. The supervisors who were affected by the flood were unaware of their responsibility to file a written report. One supervisor who did attempt to write up the incident could not complete the report because of lack of information on the value of the damaged asset. The process for submitting the NASA Mishap Report Form 1627 is cumbersome and ill-defined. Most supervisors who do not have frequent experiences with mishaps and mishap reporting are unaware that they are responsible for the paperwork. The form also requires an assessment of the value of the damaged asset, which in this case could not be determined. Finally, the form is not available on-line at Goddard, but employees are directed to request a copy from the Safety and Environmental Branch. | |
| language | English | |
| title | NASA-LLIS-1251 | num |
| title | Lessons Learned – Failure to Report an Incident as a NASA Mishap | en |
| type | standard | |
| page | 2 | |
| status | Active | |
| tree | NASA - National Aeronautics and Space Administration (NASA):;2001 | |
| contenttype | fulltext | |
| subject keywords | Administration/Organization |