DEPARTMENT OF THE AIR FORCE …static.e-publishing.af.mil/production/1/af_se/publication/afman91... · by order of the secretary of the air force air force manual 91-222 22 december

AFMAN91-222_AFGM2018-01

11 June 2018

MEMORANDUM FOR DISTRIBUTION C MAJCOMs/FOAs/DRUs

FROM: AF/SE 1400 Air Force Pentagon Washington DC 20330

SUBJECT: Air Force Guidance Memorandum to AFMAN 91-222, Space Safety Investigations and Reports

By Order of the Secretary of the Air Force, this AF Guidance Memorandum immediately implements changes to AFMAN 91-222, Space Safety Investigations and Reports. Compliance with this Memorandum is mandatory. To the extent its directions are inconsistent with other Air Force publications, the information herein prevails, in accordance with AFI 33-360, Publications and Forms Management.

This Memorandum becomes void after one year has elapsed from the date of this Memorandum, or upon publication of an Interim Change or rewrite of the affected publication, whichever is earlier.

JOHN T. RAUCH Major General, USAF Chief of Safety

1 Attachment: 1. Guidance Changes

DEPARTMENT OF THE AIR FORCE HEADQUARTERS AIR FORCE SAFETY CENTER

Attachment 1

Guidance Changes

The below changes to AFMAN 91-222, dated 22 Dec 2016, are effective immediately.

1.2.1.1. Deleted.

1.2.2. Investigate and report damage or injury to Air Force space resources or personnel as a Space mishap. This includes, but is not limited to, the following specific situations:

1.2.3. Investigate and report damage or injury involving Air Force space resources or personnel as a space mishap. This includes, but is not limited to, the following specific situations:

1.3.2. Operational Systems. For operational systems (or systems transitioned to operations), classify space events prior to the end of design life based on the impact on mission capability (MC). A program’s Capability Development Document (CDD) or other Operational Capability Requirements Document defines the MC. The document should define the primary, secondary, and tertiary MCs. Space systems may have more than one primary, secondary, or tertiary MC.

1.3.2.4. Classify loss of operational capability of a system (ground or on orbit) as determined by the MAJCOM owner, at least as a Hazard. Update event classification, as appropriate during anomaly resolution following guidance in Section 5.

1.3.3. Non-Operational Systems. Reference AFI91-204, paragraph 1.9, Exceptions to mandatory reporting requirements for this AFI, to determine reporting criteria for non-operational systems. AF/SE or MAJCOM/SE has the discretion to conduct an investigation, depending on the non-operational event.

1.3.4. Hazards. Space Safety staffs will classify any space event deemed important to investigate/report for mishap prevention, and which does not meet other reportable space mishap classification criteria and does not result in injury or damage, as a Hazard. Hazard reports provide an expeditious way to disseminate valuable mishap prevention information. As a minimum, report the following in AFSAS:

1.3.5. Incidents. Space Safety staffs will classify any space event deemed important to investigate and/or report for mishap prevention, which includes injury and/or damage but that does not meet Class A-E Mishap reporting criteria (Ex: injury and/or damage to commercial assets, whereby no injury and/or damage occurred to AF assets, but the AF can benefit from lessons learned.).

2.5.1.1 Identify and notify organizations that will incur investigation responsibility should a mishap occur.

2.7.5. At a minimum, an ISB will stand up after a declaration of a Class A or B Mishap or at the direction of the MAJCOM or HQ AFSEC/SES.

5.1. General Information. The CA determines the depth of investigative effort required for each mishap. Conduct the investigations IAW AFI 91-204 and the space-specific guidance contained in this chapter. Conduct safety investigations using a SIB or SIO. Briefing slide templates, suggested resources, and checklists are available through the AFSEC SIB SUPPORT page on the AF Portal (also see AFSAS Pubs & Refs tab). If necessary and directed by the CA, conduct Air Force safety investigations concurrently with other applicable investigations.

5.2.1. All timeline milestones begin at Event declaration. This is normally the same time that the Event occurs. For some space Events, there may be a delay between the occurrence and declaration of an Event. 5.2.1.1. Notify the CA safety office of any unresolved orbital anomaly that extends past 72 hours. The clock begins at the onset of an anomaly. If subsequent anomalies occur, the clock will not be reset for each new anomaly. Track anomalies as hazards. Once notified, the CA safety office shall observe the anomaly resolution process and transition to a safety investigation when / if enough information exists to classify the anomaly as a mishap (Class A-E). The CA may delegate to another safety office for initial anomaly status reporting. (T-2) 5.2.1.2. At any point during the anomaly process when it has been determined an anomaly meets the definition of a space mishap, declare a space mishap and start a safety investigation.

5.2.2. Complete SIB/SIO investigations within 90 days for Class A and B mishaps and 45 days for all other Events. Refer to AFI 91-204 for reporting and routing requirements.

5.4.1.2. The CA can support investigation and reporting of Class E Mishaps using a program/operation anomaly resolution process for analyzing technical data and other fact-based information. Follow guidance in AFI 91-204 for the handling of any privileged information.

BY ORDER OF THE

SECRETARY OF THE AIR FORCE

AIR FORCE MANUAL 91-222

22 DECEMBER 2016

Safety

SPACE SAFETY INVESTIGATIONS

AND REPORTS

COMPLIANCE WITH THIS PUBLICATION IS MANDATORY

ACCESSIBILITY: Publications and forms are available on the e-Publishing website at

www.e-publishing.af.mil for downloading or ordering.

RELEASABILITY: There are no releasability restrictions on this publication.

OPR: HQ AFSEC/SES

Supersedes: AFMAN 91-222, 9

AUGUST 2005

Certified by: AF/SE

(Maj Gen Andrew M. Mueller)

Pages: 30

This manual provides additional guidance for investigating and reporting space mishaps to

support Air Force Instruction (AFI) 91-204, Safety Investigations and Reports. This manual

applies to all Regular Air Force (RegAF), Air Force Reserve, and Air National Guard (ANG)

units that design, develop, modify, evaluate, test and/or operate existing and future Air Force

space systems (operational, test, and experimental), Air Force space support systems, or use or

operate Air Force launch facilities or ranges.

Request waivers to this manual as Tier-1 and coordination through the Major Command

(MAJCOM)/SE to Air Force Chief of Safety (AF/SE), unless otherwise specified in this manual.

See AFI 33-360, Publications and Forms Management, for a description of the authorities

associated with Tier numbers. Maintain all records created pertaining to processes prescribed in

this publication in accordance with (IAW) Air Force Manual (AFMAN) 33-363, Management of

Records, and dispose of IAW Air Force Records Information Management System (AFRIMS)

Records Disposition Schedule (RDS).

Any level organization may supplement this publication. Coordinate any supplements to this

publication with MAJCOM/SE before submitting to Headquarters (HQ) Air Force Safety Center,

Space Safety Division (AFSEC/SES) for review, coordination, and approval prior to publication.

Refer recommended changes and questions about this publication to the OPR using the Air Force

Form 847, Recommendation for Change of Publication; route Air Force Forms 847 from the

field through the appropriate functional chain of command to Headquarters Air Force Safety

Center / Space Safety Division (HQ AFSEC/SES), 9700 G Avenue, SE, Building 24499,

Kirtland AFB NM 87117-5670 or [email protected].

http://www.e-publishing.af.mil/

mailto:[email protected]

2 AFMAN91-222 22 DECEMBER 2016

No Technical Order (TO), Instruction or Operating Instruction (OI) can address every hazard or

potential hazard that may arise from a specific task or combination of tasks. When situations

arise not covered by existing directives, use the Risk Management (RM) process to assess risk

associated with those situations and determine adequate safeguards or procedures to manage the

risk. Refer to AFPAM 90-803, Risk Management (RM) Guidelines, and Tools, for guidance on

using the RM process.

Note 1: do not use the RM process in a manner that violates laws, directives, and/or other

regulatory guidance. Follow normal waiver and/or variance procedures in all cases (refer to this

instruction). Outside of Air Force guidance, the Air Force does not have authority to grant

exemptions and/or waivers for statutory and/or regulatory requirements that have risk-related

exposure elements or standards. Process all other waivers, variances, and/or change requests

through appropriate agencies for approval.

SUMMARY OF CHANGES

Due to substantial revisions, completely review this document. This revision provides detailed

guidance on Space Mishap and Event Classifications, and the use of the Air Force Safety

Automated System (AFSAS) for reporting.

Chapter 1— GENERAL INFORMATION 4

1.1. Purpose of Safety Investigations and Reports......................................................... 4

1.2. Space Mishaps and Events that Require Safety Investigations and Reports. ......... 4

1.3. Space Mishaps and Event Classifications. .............................................................. 5

1.4. Space Mishap Costs. ............................................................................................... 7

Chapter 2— RESPONSIBILITIES 8

2.1. General Information. ............................................................................................... 8

2.2. HQ AFSEC/SES. .................................................................................................... 8

2.3. MAJCOM Commanders. ........................................................................................ 8

2.4. The Convening Authority (CA). ............................................................................. 8

2.5. Commanders of Air Force launch and/or range operations. ................................... 8

2.6. Unit Commanders. .................................................................................................. 8

2.7. Interim Safety Board (ISB) President. .................................................................... 8

2.8. Joint/DoD/Non-DoD Space Safety Guidelines. ...................................................... 9

Chapter 3— PRIVILEGED SAFETY INFORMATION 10


AFMAN91-222 22 DECEMBER 2016 3

3.2. Releasing Recommendations. ................................................................................. 10

Chapter 4— DETERMINING INVESTIGATIVE RESPONSIBILITY 11


4.2. Determining AF Space Mishap Ownership. ........................................................... 11

4.3. Determining Commercial Space Mishap Ownership. ............................................. 11

Chapter 5— SAFETY INVESTIGATIONS 13


5.2. Investigation Timelines. .......................................................................................... 13

5.3. Investigation Funding. ............................................................................................ 13

5.4. Investigation Options. ............................................................................................. 14

5.5. Obtaining and Using Technical Assistance and Laboratory Analysis. ................... 16

Chapter 6— REPORTS AND BRIEFINGS 17


6.2. Marking Messages, Reports, Documents, and Other Safety Materials. .................. 17

6.3. Guidance for Space Mishap Formal Reports. ......................................................... 17

Chapter 7— FOLLOW-UP ACTIONS 19


7.2. Review Process. ...................................................................................................... 19

7.3. Memorandum of Final Evaluation (MOFE). .......................................................... 19

7.4. Tracking Recommendations. .................................................................................. 19

Attachment 1— GLOSSARY OF REFERENCES AND SUPPORTING INFORMATION 20

Attachment 2— WORKING WITH ACCIDENT INVESTIGATION BOARD (AIB) AND

THE ENGINEERING ANALYSIS GROUP (EAG) 29


Chapter 1

GENERAL INFORMATION

1.1. Purpose of Safety Investigations and Reports. The sole purpose of safety investigations

is to prevent future mishaps. This manual, in conjunction with AFI 91-204, Safety Investigations

and Reports, and the Air Force Safety Automated System (AFSAS), directs procedures and

provides guidance specific to the investigation and reporting of United States Air Force (USAF)

space mishaps and events in support of the Air Force Chief of Staff (CSAF) Safety Program.

Follow this manual to determine space mishap severity classification and expected safety

investigation and safety reporting requirements.

1.1.1. This manual does not cover investigations to gather evidence for claims, litigation,

disciplinary, adverse administrative actions, or for purposes other than mishap prevention.

1.1.2. Request waivers to this instruction through the Major Command (MAJCOM)/SE to

Air Force Chief of Safety (AF/SE). Unless otherwise specified in this instruction, consider

all waivers Tier 1. Note: for the purposes of this instruction, the term "MAJCOM" includes

Air National Guard (ANG), Direct Reporting Units (DRUs), and Field Operating Agencies

(FOAs).

1.2. Space Mishaps and Events that Require Safety Investigations and Reports.

1.2.1. A mishap or event is an unplanned occurrence, or series of occurrences, resulting in

damage or injury. Report any unplanned occurrence or series of occurrences meeting the

definition of a space mishap or event IAW AFI 91-204.

1.2.1.1. Classify hazardous situations that could lead to a future mishap or unplanned

operations as events.

1.2.2. Investigate and report damage or injury to Air Force space resources or personnel as a

space mishap or event. This includes, but is not limited to, the following specific situations:

1.2.2.1. The loss or damage of a space system over which the Air Force has development

and/or procurement responsibility.

1.2.2.2. Injury, illness, and/or damage to Air Force space resources that results from

government and/or contractor operations.

1.2.2.3. The loss or damage of Air Force space systems during pre-launch or launch on

commercially procured launch systems or services.

1.2.2.4. Injury, illness, and/or abnormal physiological episodes resulting from space

system operations or space system processing.

1.2.2.5. Damage or loss of space systems caused by natural phenomena within system

design parameters. Do not report the damage or loss if it is the result of unexpected and

unavoidable natural phenomena.

1.2.2.6. Damage or loss of space vehicle in space when caused by inadvertent

commanding, regardless of design life.


1.2.2.7. Damage or loss of space vehicle in space when caused by collision, regardless of

design life.

1.2.2.8. The loss or damage of a space system over which the Air Force has satellite

control authority.

1.2.2.9. Unplanned occurrence, or series of occurrences, that result in damage to a

ground based space system.

1.2.2.10. Fly-back of a system that results in damage, injury or does not execute its fly-

back maneuver as intended.

1.2.3. Investigate and report damage involving Air Force space resources or personnel as a

space mishap or event. This includes, but is not limited to, the following specific situations:

1.2.3.1. When Air Force personnel or equipment is suspected or known to have

contributed to a non-DoD Launch mishap or event (does not include normal authorized

destruct).

1.2.3.2. The failure of Air Force launch and/or range operations, procedures, or

processes to adequately protect the public or DoD operations from damage or injury (e.g.,

loading fuel, testing high-pressure equipment).

1.2.3.3. Any unauthorized creation of debris larger than 5mm.

1.2.3.4. Failure to passivate a space vehicle.

1.2.3.5. Inadvertent system actuation that results in damage, injury or creates potentially

hazardous conditions.

1.2.3.6. Re-entry of a system that results in damage, injury or does not execute its re-

entry maneuver as intended.

1.2.4. For mishaps involving radioactive material, follow AFI 91-204. If the radioactive

material has a permit from the US Air Force Radioisotope Committee or a Nuclear

Regulatory Committee (NRC) license, also follow AFI 40-201, and Title 10, Code of Federal

Regulations, Department of Energy. (T-0)

1.2.4.1. Comply with relevant additional guidance in Department of Defense Directive

(DoDD) 3150.08, DoD Response to Nuclear and Radiological Incidents. Send

Operational Reporting (OPREPs) and attach the appropriate flag word to all mishap

messages (see AFI 10-206, Operational Reporting, and CSAF OPREP-3 Reports

Matrix).

1.2.4.2. Ensure that the investigation and report addresses any radiological mishap.

1.2.5. Exception to mandatory reporting requirements. Do not report normal residual

damage as the result of a space launch.

1.3. Space Mishaps and Event Classifications. Classify mishaps IAW AFI 91-204, by total

direct mishap cost and the severity of injury/occupational illness, except as specified in the

definitions below.


1.3.1. Operational and Non-Operational Systems. Non-operational systems include research

and development satellites, test systems, and other missions that involve deliberative risk

acceptance during the acquisition development process.

1.3.1.1. Classify any failure to complete passivation and/or disposal (per AFI 91-217,

Space Safety and Mishap Prevention Program) as a Class C mishap.

1.3.1.2. Classify any unauthorized creation of orbital debris, 5mm or larger, that involves

an Air Force space system as a Class C mishap.

1.3.2. Operational Systems. For operational systems (or systems transitioned to operations),

classify mishaps or event prior to the end of design life based on the impact on mission

capability (MC). A program’s Capability Development Document (CDD) or other

Operational Capability Requirements Document defines the MC. The document should

define the primary, secondary, and tertiary MCs. Space systems may have more than one

primary, secondary, or tertiary MC.

1.3.2.1. Classify permanent loss of primary mission capability as a Class A mishap.

1.3.2.2. Classify permanent degradation of primary or secondary mission capability or

the permanent loss of secondary mission capability as a Class B mishap.

1.3.2.3. Classify permanent loss or degradation of tertiary mission capability as a Class C

mishap.

1.3.2.4. Classify loss of operational capability of a system (ground or on orbit) as

determined by the MAJCOM owner, as at least a Class E event. Update mishap or event

classification, as appropriate during anomaly resolution following guidance in Section 5.

1.3.3. Non-Operational Systems. For non-operational systems, classify mishaps as a Class E

event. Depending on the event, a non-operational system’s mishap category maybe upgraded

by AF/SE at their discretion.

1.3.3.1. Use the mission success criteria, experiment plan or other document (i.e.

Operational Requirements Document (ORD), CDD) to identify impact to mission

capability.

1.3.3.2. The document should define which aspects of the system are experimental or

high-risk, and distinguish them from high-reliability systems not expected to fail.

1.3.4. Class E Events. Space Safety staffs will classify any space event deemed important to

investigate/report for mishap prevention, and which does not meet other reportable space

mishap classification criteria, as a Class E event. Class E reports provide an expeditious way

to disseminate valuable mishap prevention information. As a minimum, report the following

in AFSAS:

1.3.4.1. A collision avoidance maneuver conducted by an on-orbit Air Force spacecraft

outside of its normal collision avoidance process. Include the miss distance and time

until predicted collision at the point when performing the maneuver.

1.3.4.2. Any loss or degradation to an on-orbit asset due to human error, even if

occurring after the component / payload / spacecraft design life.

1.3.4.3. Any hazardous event that could potentially lead to a mishap.


1.4. Space Mishap Costs. It is DoD policy to determine the total direct mishap cost in order to

provide a factual basis for the allocation of resources in support of DoD mishap prevention

programs. Determine mishap costs IAW AFI 91-204. For destroyed, lost assets, or partial

mission capable (PMC) assets with no item to exchange, use the cost from the program (DD

Form 250).


Chapter 2

RESPONSIBILITIES

2.1. General Information. Follow guidance listed in AFI 91-204, with the following space-

specific additions:

2.2. HQ AFSEC/SES. For non-DoD launches from Air Force launch facilities and/or ranges,

HQ AFSEC/SES will ensure investigation and reporting agreements allow the Air Force to

participate at least as an observer on FAA, NASA, and/or NTSB-led investigation boards. This

participation includes gathering information to put into AFSAS for future mishap prevention

purposes.

2.3. MAJCOM Commanders. Commanders will establish a process to enable timely

identification and assignment of safety investigation board (SIB) presidents and single

investigating officers (SIO) for Space Safety investigations.

2.4. The Convening Authority (CA). The CA will forward to HQ AFSEC/SES as quickly as is

practical, all critical safety information discovered by a SIB related to any relevant civil space

vehicle and commercial space equipment. HQ AFSEC/SES will forward all such non-privileged

information contributing to the promotion of Space Safety to the Federal Aviation

Administration (FAA), National Aeronautics and Space Administration (NASA), and National

Transportation Safety Board (NTSB) for appropriate action.

2.5. Commanders of Air Force launch and/or range operations.

2.5.1. Prior to each operation (e.g., launch, fly-back, re-entry), commanders of Air Force

launch facilities, and/or ranges will:

2.5.1.1. Identify and notify organizations that will incur investigation responsibility

should a mishap or event occur.

2.5.1.2. Establish an Interim Safety Board (ISB) President.

2.5.2. Launch Facility and/or Range Commanders will notify the FAA Office of Commercial

Space Transportation when a mishap and/or event occurs involving a licensed commercial

space system at Air Force launch facilities and/or ranges. During launch of a commercial

space vehicle from an Air Force launch facility and/or range, the on-site FAA representative,

if/when present, will fulfill this notification requirement and up-channel as required.

2.6. Unit Commanders.

2.6.1. The commander of the first Air Force organization to become aware of a space mishap

and/or event will notify the organization with control authority over the affected space

system.

2.6.2. For high-risk activities with significant mishap potential, the Unit Commander

identifies an ISB President prior to conducting the activity.

2.7. Interim Safety Board (ISB) President.

2.7.1. The ISB President, under certain circumstances, may have to interface with non-Air

Force organizations (e.g., Lockheed Martin (LM) Company, Northrop Grumman (NG),

National Reconnaissance Office (NRO), FAA, NASA, NTSB, commercial vendors).


2.7.2. The ISB President will follow existing agreements, when applicable, with respect to

wreckage and evidence owned by non-Air Force organizations.

2.7.3. For mishaps in which the FAA, NASA, or NTSB is the CA or lead investigating

agency, per AFI 91-204 and AFI 91-206(I), ISB members shall refrain from interviewing

witnesses until the CA or lead investigating agency representatives arrive, unless there is a

compelling reason to take the witness' statement(s) immediately (i.e., transient witnesses or

perishable evidence). (T-2)

2.7.4. Provide a hand-off briefing to SIB or SIO that marks the end of the ISB's involvement

in the investigation. Hand-off briefing will review ISB actions accomplished to date and

updated site hazard information.

2.7.5. At a minimum, an ISB will stand up after a declaration of a Class E or at the direction

of the MAJCOM or HQ AFSEC/SES.

2.7.6. The ISB is not responsible for determining mishap cause(s). The sole purpose of the

ISB is to gather, preserve and protect evidence. The ISB investigation is normally limited to

determining what evidence exists. The ISB only analyzes evidence when it will perish prior

to arrival of the permanent SIB and with CA or SIB BP permission. The ISB is responsible

for:

2.7.6.1. Notifying the owning installation of the need to collect personnel records. (T-1)

2.7.6.2. Impounding all equipment and/or data, which may relate to the mishap. The

items of interest to impound are typically in the installation’s Mishap Response Plan

(MRP). Refer to AFI 91-204 for further guidance. (T-1)

2.7.6.3. Collecting perishable fluids and photographing the mishap site. (T-1)

2.7.6.4. Preserving integrity of the evidence, ensure only ISB members have access to

the evidence pending transfer over to the SIB. (T-1)

2.7.6.5. Identifying possible witnesses and gathering preliminary statements as

appropriate. (T-1)

2.8. Joint/DoD/Non-DoD Space Safety Guidelines. All participating organizations within a

mission partnership should establish Memorandums of Agreement (MOAs) or Memorandums of

Understanding (MOUs) outlining each organization’s responsibilities and requirements with

regard to Space Safety Investigations and Reports. This includes organizations operating in a

joint environment or with non-Department of Defense (DoD) agencies. It is the participating

organizations’ responsibilities to determine the lead agency and proper approval authorities.

Refer to AFI 91-206(I), Participation in a Military or Civil Aircraft Accident Safety

Investigation, for joint investigation guidance.


Chapter 3

PRIVILEGED SAFETY INFORMATION

3.1. General Information. For privileged safety information, follow the guidance in AFI 91-

204 and the following space-specific additions:

3.1.1. Investigations involving or affecting multiple agencies require special attention to the

handling of safety information, privileged or not. SIB Presidents/SIOs will release

information collected by safety investigators to outside AF safety channels only IAW this

manual and AFI 91-204, carefully observing guidance regarding privileged information.

3.1.2. In all cases, contact the Headquarters Air Force Safety Center, Staff Judge Advocate

(HQ AFSEC/JA) for approval to release. In certain cases, the Air Force may exchange

privileged safety information with other DoD agencies solely for mishap prevention

purposes. In addition, the Air Force shares certain mishap prevention information with other

entities in the interests of the general safety community. Commonality of launch vehicles,

launch vehicle systems, components, and launch range safety systems exists for launches

conducted under launch licenses issued by the FAA and launches conducted by and for the

Air Force. The FAA and the Air Force therefore require timely knowledge of the facts and

circumstances of commercial space launch accidents. Reference 14 Code of Federal

Regulations (CFR), Part 401.5.

3.1.2.1. An Air Force safety investigator discovering a critical safety concern applicable

to commercial spaceflight will provide that information to HQ AFSEC/SES for

consideration of release to other organizations IAW AFI 91-204.

3.1.2.2. Send all Freedom of Information Act (FOIA) requests, subpoenas, or other

requests involving safety information protected by the military safety privilege to HQ

AFSEC/JA, IAW AFI 91-204.

3.1.3. When the Air Force participates in an investigation led by the NTSB, FAA or NASA,

the Air Force will protect all investigation data, information, documents, or other material as

prescribed by the investigating agency. The Air Force will not disclose this information in

any manner without the written consent of the Investigator-in-Charge. In addition, the Air

Force will refer any FOIA request, subpoena, or other request for such information to the

NTSB, FAA or NASA for resolution.

3.2. Releasing Recommendations. Only HQ AF may release an AF investigative board’s

conclusion attributing cause to another agency or recommendation of corrective action by

another agency, IAW AFI 91-204. For the release of safety information to the FAA, NASA or

the NTSB for space mishaps, use AFI 91-206 as a guide.


Chapter 4

DETERMINING INVESTIGATIVE RESPONSIBILITY

4.1. General Information. The Air Force generally assigns investigative responsibilities to the

MAJCOM experiencing operational loss of an assigned/owned asset (personnel or property).

Unless otherwise stated, the mishap owner (as determined IAW AFI 91-204) has investigative

responsibility for the mishap.

4.1.1. The CA is the individual who has the authority to order a safety investigation.

4.1.2. The MAJCOM/CC of the organization that owns the asset is the CA unless: AF/SE

assumes investigative responsibility, another MAJCOM/CC assumes investigative

responsibility (with the concurrence of the owning organization and AF/SE), or investigative

responsibility is delegated to a lower level of command.

4.2. Determining AF Space Mishap Ownership. The mishap owner is that unit which has

permanent possession and mishap reporting accountability for the affected asset and/or personnel

involved in the mishap. Assign ownership of the space mishap to the MAJCOM responsible for

the space system at the time of the mishap.

4.2.1. For satellites, assign mishap ownership to the MAJCOM with satellite control

authority.

4.2.1.1. Satellite control authority for an on-orbit space system, or the debris associated

with it, does not end until: re-entry and touchdown on Earth; transfer of responsibility to

another agency; or injection into an Earth-escape trajectory as part of the end-of-life

process (e.g., satellite control authority does not end for space systems in a non-

operational orbit).

4.2.1.2. For non-operational satellites, the last organization with SCA maintains SCA for

the purposes of mishap reporting.

4.2.2. For launch vehicles, including upper stages, assign ownership of the mishap to the

MAJCOM acquiring the launch vehicle unless an agreement is in place specifying transfer of

ownership to another agency.

4.2.3. Aerospace Vehicle Contractor Mishaps Involving Air Force Indemnification. For

operations involving unusually hazardous safety risks that the Air Force indemnified, such as

contractor provided launch services for Air Force or National Security Space payloads, the

MAJCOM that acquired the operational service is the CA for the mishap.

4.2.4. If the Air Force leads a safety investigation, HQ AFSEC/SES will consider providing

the FAA, NASA, or the NTSB the opportunity to participate in the investigation according to

each agency’s respective role or interest.

4.3. Determining Commercial Space Mishap Ownership.

4.3.1. Depending on the circumstances, commercial space asset mishaps within US

jurisdiction may be investigated by the FAA, NASA, NTSB, and/or the commercial vendor.

If the FAA/NTSB leads such an investigation, it is implicit the FAA/NTSB will retain


custody of evidence for the duration of the investigation whether referring to physical or

intellectual (i.e. witness accounts).

4.3.2. Reference existing MOAs/MOUs to determine the correct mishap investigation

agency for commercial space mishaps.


Chapter 5

SAFETY INVESTIGATIONS

5.1. General Information. The CA determines the depth of investigative effort required for

each mishap/event. Conduct the investigations IAW AFI 91-204 and the space-specific guidance

contained in this chapter. Conduct safety investigations using a SIB or SIO. Briefing slide

templates, suggested resources, and checklists are available through the AFSEC SIB SUPPORT

page on the AF Portal (also see AFSAS Pubs & Refs tab). If necessary and directed by the CA,

conduct Air Force safety investigations concurrently with other applicable investigations.

5.2. Investigation Timelines.

5.2.1. All timeline milestones begin at mishap declaration. This is normally the same time

that the mishap occurs. For some space mishaps/events, there may be a delay between the

occurrence and declaration of mishap/event.

5.2.1.1. Notify the CA safety office within 72 hours of any unresolved anomaly. The

CA safety office shall observe the anomaly resolution process and transition to a safety

investigation when / if enough information exists to classify the anomaly as

mishap/event. The CA may delegate to another safety office for initial anomaly status

reporting. (T-2)

5.2.1.2. At any point during the anomaly process when it has been determined an

anomaly meets the definition of a space mishap/event, declare a space mishap/event and

start a safety investigation.

5.2.2. Complete SIB/SIO investigations within 90 days for Class A and B mishaps and 45

days for all other mishaps/events. Refer to AFI 91-204 for reporting and routing

requirements.

5.2.3. Due to the complexity of the data recovery and engineering analysis process, space

mishaps might require longer timeframes. If circumstances prevent meeting a timeline, the

board president/SIO may request an extension from the CA. The SIB/SIO annotates the

extension and approval by the CA in each status message. AF/SE has the authority to reject

any extension request in order to ensure the timely completion of a safety investigation.

5.3. Investigation Funding.

5.3.1. Follow the funding guidance in AFI 91-204.

5.3.2. Observers to an Air Force SIB fund their own TDY.

5.3.3. Additional Funding Guidance for Mishaps Involving Civil and Commercial Space

Assets. If the Air Force is the CA or the mishap owner for a mishap involving civil or

commercial space mishaps, use the following funding guidance:

5.3.3.1. In general, if the space mishap occurs at a facility not located on an Air Force

installation, then the home base of the investigating organization acts as the host

installation for the investigation and is responsible for providing and funding local

support.


5.3.3.2. To properly investigate space mishaps, there may be a need for multiple host

installations. The closest Air Force base to the mishap site, to an investigation location

(contractor/civil/government), and to the investigation organization’s home location will

fund and provide in-house support at the request of the board president.

5.3.3.3. See AFI 91-204 for expenses that exceed the resources of the host installation.

5.4. Investigation Options.

5.4.1. The CA determines the size and membership of the safety investigation based on the

category and complexity of the mishap. Investigations can utilize multiple members (SIB) or

SIO.

5.4.1.1. As a minimum, AF safety investigations must have an SIO appointed. A space

mishap SIO should be a space professional and graduate of formal Air Force safety

training and mishap investigation courses.

5.4.1.2. The CA can support investigation and reporting of Class E events using a

program/operation anomaly resolution process for analyzing technical data and other

fact-based information. Follow guidance in AFI 91-204 for the handling of any

privileged information.

5.4.2. At least one SIB member must be at least equal in grade to the senior person directly

involved in the mishap. Normally, the SIB president is the senior SIB member. The Board

President should be the senior person on a SIB. The CA may tailor the following personnel

requirements, limitations, and restrictions for Primary and Non-Primary SIB Members as

appropriate for space mishaps:

5.4.2.1. Safety Investigation Board President, a space professional and graduate of

formal Air Force safety training and mishap investigation courses.

5.4.2.2. Air Force Safety Center Representative. HQ AFSEC/SES has the option to

provide a representative or advisor to the SIB for on-duty Class A mishaps, unusual high

interest off-duty Class A mishaps, and complex Class B mishaps, as determined by

AFSEC/SES and CA. AFSEC will fund the representative. AFSEC/SES will offer

telephonic support for all Class A mishaps. A HQ AFSEC/SES representative assigned

to the SIB is a primary member and acts as the investigation process expert to guide SIB

procedures. A HQ AFSEC/SES advisor supports the SIB as a non-primary member. The

HQ AFSEC/SES representative or advisor is the single point of contact with AFSEC for

the duration of the investigation.

5.4.2.3. Space Operations Officer, qualified or previously qualified, in the operational

use of the space system involved in the mishap.

5.4.2.4. Space Materiel Officer or Acquisition Officer, qualified in the maintenance,

engineering, or manufacturing of the space system involved in the mishap.

5.4.2.5. Weather Officer or Space Environmental Expert, if weather, weather service, or

space environment is suspect or a known factor in the mishap.

5.4.2.6. For mishaps involving potential human error, the medical member must be a

flight surgeon graduated from the USAF School of Aerospace Medicine mishap

investigation course.


5.4.2.6.1. Any appropriate expert when mishaps involve areas not specified in

5.4.2.1.-5.4.2.6. (e.g., appropriate human factor professional, medical officer,

environmental scientist).

5.4.2.7. Non-primary SIB Members.

5.4.2.7.1. The CA may select non-primary SIB members at his/her discretion.

5.4.2.7.2. Representatives to serve as liaisons, advisors, or consultants. This may

include the FAA, NASA, NTSB, or joint service observers. Refer to applicable

MOAs/MOUs for specific requirements.

5.4.3. Use of Non-Air Force Investigations. While the Air Force is always responsible for

determining the cause of Air Force mishaps, in certain situations the Air Force may accept

the results of a non-Air Force investigation to satisfy Air Force mishap prevention

requirements as directed by the CA. The FAA, NASA, NTSB, or the space system owner

will usually investigate commercial space mishaps. When possible, the Air Force should

make use of these investigations and limit duplicative investigations. However, the Air

Force always retains the right to conduct a separate Air Force safety investigation.

5.4.3.1. The Air Force will observe all investigations related to the mishap IAW this

document, the applicable MOAs/MOUs, and AFI 91-206. Air Force observers will

contact the appropriate MAJCOM Safety office or AFSEC/SES for guidance on current

agreements with the FAA, NASA, NTSB, and the responsible commercial entity.

5.4.3.2. The Air Force observer reports to the CA on the adequacy of the investigation,

the validity of the conclusions, and advises on whether the conclusions satisfy Air

Force’s mishap prevention needs.

5.4.3.3. Based on the Air Force observer’s assessment on the adequacy of the non-Air

Force investigation report, the Air Force CA may accept it with a cover letter from the

Air Force observer stating acceptance of findings and submit as the Air Force final

report. The Air Force observer will ensure the prepared report and cover letter contain

non-privileged information. Alternately, the CA may appoint another SIO to evaluate the

report and deliver an Air Force mishap report. In this case, the Air Force report shall

include the non-Air Force report. (T-1)

5.4.3.4. If the Air Force CA determines that the investigation will not satisfy the Air

Force’s mishap prevention needs, the Air Force will conduct its own investigation within

the terms of applicable contracts and agreements.

5.4.4. Air Force Participation in non-Air Force Investigations. When the Air Force

participates in another service’s or government agency's investigation, AFSEC will contact

the MAJCOM(s) that can best meet the requirement. The MAJCOM/SE will coordinate the

selection of the participant with AFSEC/SES. Once AF/SE approves the nominee,

AFSEC/SES will provide a fund site to the MAJCOM and establish direct communication

with the individual. Air Force representatives to Joint Safety Investigations should be

graduates of formal Air Force safety training courses.

5.4.5. Use of Air Force Observers on Non-Air Force Investigations. Outside agencies such

as the FAA, NASA, or the NTSB may allow Air Force personnel to participate as official

observers to investigations led by these agencies. Air Force observers will adhere to the


applicable MOAs/MOUs, AFI 91-206, and the provisions of Title 49 CFR, Part 831, as

applicable.

5.4.5.1. Observers are not formal Air Force safety investigators and cannot offer

promises of confidentiality per AFI 91-204.

5.4.5.2. Air Force observers may participate but may not interfere with the observed

investigation. Air Force observers will refrain from making judgment calls, providing

opinions, or analysis, or writing any part of the report unless specifically requested to do

so by the lead investigating agency.

5.4.5.3. Air Force observers may not observe multiple investigations simultaneously nor

may they participate in any other investigations while still acting in an observer status.

Observers may transition from an Air Force observer to an Air Force SIB to provide the

SIB with continuity; however, once transferred, may no longer serve as an Air Force

observer or transfer back to observer status.

5.4.6. Personnel observing or participating in an investigation will be under the control and

direction of the lead agency's chief investigator (e.g., NTSB "Investigator-In-Charge," or

FAA "Investigator-In-Charge"). All such personnel will follow the lead agency's rules

regarding the handling and/or release of information, or other evidence collected during an

investigation.

5.5. Obtaining and Using Technical Assistance and Laboratory Analysis. The contractor

and the system program office, in coordination with the SIB and Accident Investigation Board

(AIB) presidents, may establish an Engineering Analysis Group (EAG) or similar to assist in

analyzing the technical data from a mishap. Refer to Attachment 2, AFI 51-503 and the launch

or space system contract.

5.5.1. For space mishaps, the EAG conducts a technical examination of mishap data. It

provides important fact-based (non- privileged) analysis to the SIB and the AIB and assures

the release of this fact-based information as soon as possible to the Commercial Space

Industry.

5.5.2. The SIB and the AIB will pass fact-based mishap data to the EAG. The EAG will

pass the results of its engineering analysis to both the SIB and the AIB as soon as it is

available.

5.5.3. The EAG’s engineering analysis is non-privileged information.

5.5.3.1. If the EAG’s engineering analysis is classified, the information owner must

clearly mark and control appropriately.

5.5.3.2. If the engineering analysis contains proprietary information, the information

owner must clearly mark and control appropriately.

5.5.4. The EAG will provide updates, as directed by the SIB president or SIO, to SIB or ISB

members on the status of the engineering analysis. SIB members may monitor the EAG but

will not direct or provide input to the EAG.


Chapter 6

REPORTS AND BRIEFINGS

6.1. General Information. Safety reports include messages (preliminary, 10-day, status, final,

and final supplemental), formal reports, injury and occupational illness forms, and logs. Safety

reporting will be via the AFSAS. Use the following URL for AFSAS:

https://afsas.af.mil/Home.do. If AFSAS is not available, contact HQ AFSEC/SES for

transmission alternatives at [email protected]. Once the SIB/SIO completes the

investigation, finalizes the formal report, and the final message, the SIB/SIO will normally

provide a briefing to the CA. Space mishaps involving fatalities, or other mishaps when

requested, require a briefing to the CSAF and Secretary of the Air Force (SECAF). AF/SEI will

be the focal point for scheduling all briefings to the CSAF and SECAF and will coordinate with

HQ AFSEC/SES.

6.1.1. Report space mishaps in accordance with AFI 91-204.

6.1.2. When a non-Air Force organization’s report exists that fulfills the requirements of an

Air Force final report, the CA may use it as the official final investigation report. Complete a

report in AFSAS and include the non-Air Force organization’s report.

6.2. Marking Messages, Reports, Documents, and Other Safety Materials.

6.2.1. Space mishap messages and safety reports are subject to limited distribution, and

control therein appropriately.

6.2.2. Make every effort to keep investigative reports and briefings unclassified to ensure the

widest dissemination possible. Report the unclassified portion of the report (i.e., one-liner,

date, time, location, Investigating Officer, and objects) using AFSAS. Do not input DoD

Unclassified Controlled Nuclear Information (DCNI) into AFSAS.

6.2.2.1. Report classified mishaps IAW the template in AFI 91-204. The SIO or SIB

President will place the final report on a mission owning unit-shared drive IAW the

Security Classification Guide (SCG) of the system with copies provided to the MAJCOM

and AFSEC safety work centers, as security guidance permits. (T-2)

6.2.2.2. Mark classified pages in messages, reports, or other safety documents with the

proper security classification marking from the appropriate SCG and AFI 16-1404, Air

Force Information Security Program.

6.2.3. For materials containing privileged information, follow the guidance in AFI 91-204.

Place the Privilege Warning statement IAW AFI 91-204, at the foot of each page that

contains privileged information. Do not place the Privilege Warning on unclassified, non-

privileged pages, on preliminary messages, or on other fact-based only material.

6.2.4. For each page that contains proprietary information, as identified by a contractor,

include an appropriate proprietary information warning. This warning must identify the

extent of the protection required (e.g., Government Only, Air Force Only).

6.3. Guidance for Space Mishap Formal Reports. Formal safety reports present detailed

information, both fact-based and analytical, about mishaps. Prepare them IAW AFI 91-204 and

the following guidance:

https://afsas.af.mil/Home.do

mailto:[email protected]


6.3.1. Distributing the Formal Report. The CA will ensure the upload of all non-waivered

formal reports into AFSAS. All Air Force agencies with a need to know can access the tabs

or request tab access via AFSAS. If the report references a document, attach a copy of the

document to the AFSAS report.

6.3.2. Do not provide copies or extracts to agencies outside the Air Force. If an agency

outside the Air Force requires a copy of the formal report for mishap prevention, corrective

actions, or other purpose, notify HQ AFSEC/JA. Distribute formal reports IAW AFI 91-204.


Chapter 7

FOLLOW-UP ACTIONS

7.1. General Information. Reviewing authorities, CAs, and HQ AFSEC/SES will conduct

follow-up actions to ensure program compliance, hazard mitigation, and trending validity. These

three areas are core safety functions required at every level. Follow guidance in AFI 91-204.

7.2. Review Process. CA safety staffs will review messages and formal reports prior to release

in AFSAS for AFI compliance, completeness, and accuracy. Although SIBs/SIOs retain

authority for all substantive report changes, the report must comply with this AFMAN and AFI

91-204.

7.3. Memorandum of Final Evaluation (MOFE). HQ AFSEC/SES prepares a MOFE for each

Class A and Class B mishap. Refer to AFI 91-204, Chapter 7, for more details on this process.

7.4. Tracking Recommendations. Manage corrective actions, with or without a MOFE, IAW

with AFI 91-204, Chapter 7.

ANDREW M. MUELLER, Major General, USAF

Chief of Safety


Attachment 1

GLOSSARY OF REFERENCES AND SUPPORTING INFORMATION

References

DoDD 3150.08, DoD Response to Nuclear and Radiological Incidents, 20 January 2010

DoDM 5200.01-V4, DoD Information Security Program: Controlled Unclassified Information

(CUI), 24 February 2012

DoD5400.7-R_AFMAN33-302, Freedom Of Information Act Program, 21 October 2010

(Incorporating Through Change 2, 22 January 2015)

DoDI 5000.02, Operation of the Defense Acquisition System, 7 January 2015

DoDI 6055.07, Mishap Notification, Investigation, Reporting, and Record Keeping, 6 June 2011

DoD 6025.18-R, DoD Health Information Privacy Regulation, 24 January 2003

AFI 10-206, Operational Reporting, 11 June 2014

AFI 10-601, Operational Capability Requirement Development, 6 November 2013

AFI 16-1404, Air Force Information Security Program, 29 May 2015

AFI 33-322, Records Management Program, 4 June 2012 (Incorporating Change 1, 18

December 2014)

AFI 33-360, Publications and Forms Management, 25 September 2013

AFI 36-3701, Space Professional Development Program, 20 May 2010

AFI 40-201, Radioactive Materials (RAM) Management, 17 September 2014

AFI 51-503, Aerospace and Ground Accident Investigations, 15 April 2015

AFI63-101/20-101, Integrated Life Cycle Management (ILCM), 07 MARCH 2013

AFI 91-110, Nuclear Safety Review and Launch Approval for Space or Missile Use of

Radioactive Material and Nuclear Systems, 13 January 2015

AFI 91-202, The US Air Force Mishap Prevention Program, 24 June 2015

AFI 91-204, Safety Investigations and Reports, 12 February 2014 (corrective actions applied on

14 April 2014)

AFI 91-206, Participation in a Military or Civil Aircraft Accident Safety Investigation, 8 July

2004

AFI 91-217, Space Safety and Mishap Prevention Program, 11 April 2014

AFMAN 33-363, Management of Records, 1 March 2008, (Incorporating Change 1, 28 January

2015)

AFMAN 91-221, Weapons Safety Investigations and Reports, 21 August 2015

AFMAN 91-223, Aviation Safety Investigations and Reports, 16 May 2013

AFPAM 90-803, Risk Management (RM) Guidelines, and Tools, 11 February 2013


Military Standard (MIL-STD) 882E, Department of Defense Standard Practice System Safety, 11

May 2012

TO 00-35D-54, USAF Deficiency Reporting and Investigating System

TO 1-1-638, Repair and Disposal of Aerospace Vehicles

DOD-HDBK-343 (USAF) Design, Construction, and Testing Requirements for One of a Kind

Space Equipment, 1 February 1986

Abbreviations and Acronyms

AF— Air Force

AF/SE— Air Force Chief of Safety

AFI— Air Force Instruction

AFMAN— Air Force Manual

AFRIMS— Air Force Records Information Management System

AFSAS— Air Force Safety Automated System

AFSCN— Air Force Satellite Control Network

HQ AFSEC/SES— Headquarters Air Force Safety Center, Space Safety Division

HQ AFSEC/JA— Headquarters Air Force Safety Center, Staff Judge Advocate

AIB— Accident Investigation Board

ANG— Air National Guard

C2 CIF— Command and Control Controller Information File

CA— Convening Authority

CAC—Common Access Card

CDD— Capability Development Document

CFR— Code of Federal Regulations

CJCS— Chairman of the Joint Chiefs of Staff

CP— Command Post

CPI— Critical Program Information

CPD— Capability Production Document

CSAF— Chief of Staff, United States Air Force

DCNI— DoD Unclassified Controlled Nuclear Information

DCR – DOTMLPF—P Change Recommendation

DoD— Department of Defense

DoDD— Department of Defense Directive

DoDM— Department of Defense Manual


DRU— Direct Reporting Unit

EAG— Engineering Analysis Group

FAA— Federal Aviation Administration

FOA— Field Operating Agency

FOIA— Freedom of Information Act

FOUO— For Official Use Only

HQ— Headquarters

IAW— In Accordance With

ICBM— Intercontinental Ballistic Missile

ICD— Initial Capabilities Document

ILCM— Integrated Life Cycle Management

ISB— Interim Safety Board

JA— Judge Advocate

JCIDS— Joint Capabilities Integration and Development System

LSO— Launch Safety Officer

MAJCOM— Major Command

MC— Mission Capability

MOA— Memorandum of Agreement

MOU— Memorandum of Understanding

NASA— National Aeronautics and Space Administration

NRC— Nuclear Regulatory Committee

NRO— National Reconnaissance Office

NTSB— National Transportation Safety Board

MRP— Mishap Response Plan

OCA— Original Classification Authorities

OI— Operating Instruction

OPR—Office of Primary Responsibility

OPREP— Operational Reporting

ORD— Operational Requirements Document

PMC— Partial Mission Capable

RDS— Records Disposition Schedule

RegAF— Regular Air Force


RM— Risk Management

RPA— Remote Piloted Aircraft

SCA— Satellite Control Authority

SCCS— Space Command and Control Systems

SCG— Security Classification Guide

SECAF— Secretary of the Air Force

SIB— Safety Investigation Board

SIO— Single Investigation Officer

SSE— Space Support Equipment

SSO— Space Safety Officer

TO— Technical Order

UAS— Unmanned Aerial System

USAF— United States Air Force

Terms

ACCIDENT INVESTIGATION BOARDS (AIB)— Accident investigations are conducted by

accident investigation boards (AIB) to inquire into all the facts and circumstances surrounding

Air Force aerospace and ground accidents, to prepare a publicly-releasable report, to obtain and

preserve all available evidence for use in litigation, claims, disciplinary action, and adverse

administrative action. An accident investigation consists of a board president, legal advisor, and

other board members as required or necessary.

ACCEPTABLE RISK— a risk that the appropriate acceptance authority (as defined in DoDI

5000.02) is willing to accept without additional mitigation. (MIL-STD-882E)

AEROSPACE VEHICLES— DoD aircraft, Remotely Piloted Aircraft (RPA)/Unmanned

Aerial System (UASs), missiles, spaceplanes (X-37), and space vehicles.

AIR FORCE LAUNCH— Any space launch operation conducted with significant oversight or

insight by the Air Force and not subject to licensing requirements of 14 CFR, Part 415. The Air

Force may or may not be the space system owner.

AIR FORCE SAFETY AUTOMATED SYSTEM (AFSAS)— Safety reporting will be via the

AFSAS. AFSAS is a CAC-enabled system that ensures the protection of privileged information.

To protect the privileged status and to ensure the correct handling of safety reports, originating

organizations will use the AFSAS reporting system to transmit messages. Use the following

URL for AFSAS: https://afsas.af.mil/Home.do.

ANOMALY— An unexpected or unplanned condition that does not meet provided system

performance parameters and which cannot be corrected by organizational maintenance resources

in accordance with validated procedures. After analysis, an “out-of-family” condition could be

declared an anomaly.

https://afsas.af.mil/Home.do


ANOMALY RESOLUTION PROCESS— Process used to resolve a spacecraft anomaly.

Typically conducted by the operating/testing organization (squadron or equivalent level).

CAUSE— A cause is a deficiency, which if corrected, eliminated, or avoided, would likely have

prevented or mitigated the mishap damage or significant injury.

CONTRACTOR MISHAP— A mishap resulting from contractor operations that involves

injury to DoD personnel and/or damage to DoD resources. Note: when determining if a

contractor employee’s injury or illness requires reporting for recordkeeping requirements under

29 CFR 1904 refer to Chapter 1 of AFI 91-204.

CONVENING AUTHORITY (CA)— The individual who has the authority to order a safety

investigation.

CSAF OPREP—3 REPORTS MATRIX - The CSAF OPREP-3 Reports Matrix is a quick

reference list to assist commanders and controllers in determining the level and type of report to

submit based on events and incidents deemed of interest to the CSAF, Chairman of the Joint

Chiefs of Staff (CJCS). As operational situations evolve the need to update reporting

requirements as AF/A3O or higher directs, the CSAF OPREP-3 Reports Matrix are posted on the

Command Post (CP) Intelink Site.

ENGINEERING ANALYSIS GROUP (EAG)— An independent group of contractor

personnel, Air Force representatives, and other experts established to assist the SIB and AIB in

analyzing the technical data from a space mishap investigation. The EAG may recommend to

the SIB president and AIB president that certain non-privileged evidence and equipment be

released while the investigations are pending in order that space launches may continue.

EVENT— An unplanned occurrence, or series of occurrences, that does not meet the reporting

criteria of a mishap.

FAA LICENSED LAUNCH— Any commercial launch or re-entry issued a license by Federal

Aviation Administration’s Office of Commercial Space Transportation.

FINDINGS— Findings are what the safety investigator concluded and are statements, in

chronological order, of the significant events sustaining the sequence leading to the mishap.

FOR OFFICIAL USE ONLY (FOUO)— A protective marking to be applied to unclassified

information when disclosure to the public of that particular record, or portion thereof, would

reasonably be expected to cause a foreseeable harm to an interest protected by one or more

provisions of the Freedom of Information Act (FOIA). This includes information that qualifies

for protection pursuant to the provisions of the Privacy Act of 1974, as amended. See

DOD5400.7-R_AFMAN33-302, Freedom of Information Act Program, for detailed information

on categories of information that may qualify for exemption from public release.

FORMAL REPORTS— Formal reports present detailed factual and analytical information

about mishaps. AFSAS is the only acceptable method for mishap reporting. Upload formal

reports as tabs into AFSAS. All Class A and B space mishaps require a formal report unless

waived by the Air Force Chief of Safety (AF/SE). The CA or AF/SE may also require a formal

report for any other mishap if determined necessary.

GROUND—BASED SPACE SYSTEM MISHAP – Ground-based space systems include

unique space support equipment as well as space-related systems that do not directly support

launch operations or on-orbit satellite operations. Examples include warning, surveillance, and


offensive/defensive space control systems such as the Space Surveillance Network, the Rapid

Attack Identification, Detection and Reporting System (RAIDRS), and the Integrated Tactical

Warning and Attack Assessment (ITW/AA) system.

HAZARD— Any real or potential condition that can cause injury or occupational illness to

personnel; damage to or loss of a system, equipment or property; or damage to the environment.

INDUSTRIAL SPACE MISHAP— Mishaps occurring in the industrial environment that

involve space systems (pre-launch) or unique space support equipment. Use this subcategory for

cross-categorization to ground, and industrial space mishaps only.

INJURY— A traumatic wound or other condition of the body caused by external force or

deprivation (fractures, lacerations, sprains, dislocations, concussions, compressions, drowning,

suffocation, exposure, cold injury, and dehydration), including stress or strain, which results

from an unplanned event. The injury is identifiable as to the time and place of occurrence and

member or function of the body affected, and caused by a specific event, incident, or series of

events or incidents in a single day or work shift.

LAUNCH—(T=0). When the count (predicted count status in days, hours, minutes, and seconds

to a scheduled event such as liftoff or first motion of a vehicle) is zero and first motion (an

indication of launch or test event) occurs (Range Commanders Council Publication 209-90_

Event Status, September 2009).

LAUNCH MISHAP— Space mishaps occurring during launch vehicle operations, including

upper stages. This includes payloads that do not obtain orbit or range safety system failures.

MISHAP— A mishap is an unplanned occurrence, or series of occurrences, that result in

damage or injury and meets Class A, B, C, or D reporting criteria IAW AFI 91-204, paragraph

1.10. Damage or injury includes: damage to DoD property (excluding normal wear and tear or

aging); occupational illness to DoD military or civilian personnel; injury to DoD military

personnel on- or off-duty; injury to on-duty DoD civilian personnel; damage to public or private

property, or injury or illness to non-DoD personnel caused by Air Force operations. For space

mishap, it also includes permanent or partial mission loss.

MISHAP COSTS— Mishap costs consist of two parts: Direct mishap costs ONLY include

property damage costs (DoD and Non-DoD) and environmental cleanup costs. Injury and illness

costs are part of the TOTAL mishap costs and are automatically calculated in AFSAS.

MISSION CAPABILITY (MC)— This term encompasses the purpose and functions of the

space system (sensors, transponders, etc.…) throughout its intended system mean mission

duration (the expected life of the space vehicle).

NUCLEAR MISHAP— An Air Force mishap involving radioactive material.

OPERATIONAL CAPABILITY REQUIREMENTS DOCUMENT—A document that

specifies the operational requirements for a system. It outlines a militarily useful increment of

capability with its own set of attributes and performance values (i.e., thresholds and objectives).

Examples include the Initial Capabilities Document (ICD), Information System Initial

Capabilities Document (IS-ICD), Capability Development Document (CDD), Draft CDD,

Information System Capability Development Document (IS-CDD), Capability Production

Document (CPD), or Joint DOTMLPF-P Change Recommendation (DCR) [DOTMLPF-P -

Doctrine, Organization, Training, Materiel, Leadership and Education, Personnel, Facilities, and


Policy (Where “m” is non-developmental materiel)]. Additional information is located on the

AF/A5R-P Requirements website and the Joint Capabilities Integration and Development System

(JCIDS) Manual. Many AF systems have been developed and procured pre-JCIDS using an

Operational Requirements Document (ORD). Requirements changes to programs developed

using an ORD will normally require a new JCIDS document.

ORBITAL MISHAP— Space mishaps occurring during spacecraft operation after separation

from all launch vehicle components, including upper stages and transfer motors.

OPREP—3 - The OPREP-3 system provides CSAF and intermediate commanders the

information necessary for timely operational decisions. The main criterion for inclusion in the

OPREP-3 system is essential information for command and control of aerospace forces.

PASSIVATION— The process of removing stored energy that could result in an explosion or

deflagration from a space system at end-of-life. This includes electrical, mechanical, chemical,

or nuclear energy.

PRE-LAUNCH MISHAP— Space mishaps occurring during ground handling, processing, and

transportation operations.

PROPERTY DAMAGE— Damage to facilities, equipment, property, materiel, or resources. If

the mishap or event meets reporting criteria, then the cost of environmental cleanup shall be

included in property damage costs. Report inadvertent releases of ozone depleting substances

when they meet mishap criteria.

REACTOR AND RADIOLOGICAL MISHAP— Mishaps involving fissile material used in a

self-supporting chain reaction (i.e., nuclear fission) to produce heat and/or radiation for both

practical application and research and development.

REACTOR SYSTEM— A nuclear reactor with any associated nuclear or non-nuclear systems.

RECOMMENDATIONS— Recommendations are feasible and effective solutions to eliminate

identified hazards, or if the hazard cannot be eliminated, to mitigate the hazard’s potential

consequences. Actions likely to prevent a similar mishap or reduce its effects.

REUSABLE LAUNCH VEHICLE (RLV)— a launch vehicle that is designed to return to

Earth substantially intact and therefore may be launched more than one time or that contains

vehicle stages that may be recovered by a launch operator for future use in the operation of a

substantially similar launch vehicle. (CFR, Title 14, Chapter III, Subchapter A, Part 401).

RISK LEVE—L - The characterization of risk as High, Serious, Medium, or Low IAW with

MIL-STD-882.

SATELLITE ANOMALY RESOLUTION TEAM (SART)— This team helps to resolve a

spacecraft anomaly. Typically conducted by the operating/testing organization (squadron or

equivalent level).

SAFETY INVESTIGATOR— An individual authorized and qualified to investigate a safety

mishap (e.g., members of an ISB, SIB or SIO, members of a safety staff).

SAFETY REPORT— Safety reports include message reports (preliminary, status, and final),

formal reports, and injury and occupational illness forms and logs.


SATELLITE CONTROL AUTHORITY (SCA)— The authority to plan, schedule, and

perform satellite commanding.

SECURITY CLASSIFICATION GUIDE (SCG)— The Security Classification Guide (SCG)

details how information will be classified and marked on an acquisition program. It is the

written record of an original classification decision or series of decisions regarding a system,

plan, program, or project. The SCG addresses each Critical Program Information (CPI), as well

as other relevant information requiring protection, including export-controlled information and

sensitive but unclassified information. Issue classification and declassification guidance as soon

as practical in the life cycle of the system, plan, program, or project to ensure only information

requiring protected is identified. Original Classification Authorities (OCAs) may use

memoranda and other communication media to issue classification guidance, but the preferred

method is a SCG, per AFI 16-1404.

SPACE ANOMALY— An on-orbit malfunction of a space system, or a deviation from what is

consistent with normal operations. May utilize the anomaly resolution process when initially

investigating an anomaly. A space anomaly may or may not result in damage, injury, or mission

impact that reaches the level of a reportable mishap. A space anomaly may be a reportable

event.

SPACE BOOSTER— A space vehicle designed to propel or carry another space vehicle from

the earth’s surface or from orbit to a desired point and velocity in space. This term includes

engines, rocket motors, upper stages, fuel tanks, and guidance and control sections.

SPACE COMMAND AND CONTROL SYSTEMS (SCCS)— Systems required to provide:

telemetry, tracking, commanding, mission data dissemination, data processing, communication,

and range support for space vehicles. SCCS examples include the common user Air Force

Satellite Control Network (AFSCN) and other program-dedicated networks.

SPACE MISHAP— An Air Force mishap involving a space system and/or unique space

support equipment. Includes permanent or partial mission loss of a space system.

SPACE PROFESSIONALS— Personnel with space expertise and knowledge, governed by

Space Professional Development Program certification, who are directly responsible for fielding,

launching and employing space power. This group includes space operators, scientists,

engineers, program managers, intelligence, weather, and communications personnel (AFSC 13S,

14N, 15W, 17D, 61X, 62E, 63A, 1C6, 1N0/1/2/4/5, 1W0 and selected 3D1) who require

specialized space education, experience coding and tracking to meet certification requirements.

SPACE SAFETY OFFICER (SSO)— Personnel assigned to a Space Mishap Prevention or

Mishap Investigation role. These positions include: System Safety Manager, Ground Based

Space Safety Officer, Launch Safety Officer (LSO), and Orbital Safety Officer.

SPACE SYSTEMS— Any system used for space operations or support. Space system is a

generic term used to encompass all ground, space and link segment systems and their

components. All the devices and organizations forming the space network are space systems.

These consist of: launch vehicles, launch ranges, launch and range support equipment and

systems, spacecraft, ground and airborne stations, and data links among spacecraft, mission, and

user terminals.


SPACE VEHICLE— A vehicle designed to orbit or travel beyond the earth’s atmosphere or a

system designed to lift other space vehicles into orbit. Examples of space vehicles include

boosters (launch vehicles), spacecraft (satellites, orbiters, payloads) and reusable spacecraft.

Intercontinental Ballistic Missiles (ICBMs) are not considered space vehicles.

SPACECRAFT— A space vehicle designed to operate in space and launched by a booster. The

term includes satellites, orbiters and payloads, and their associated subsystems. This includes

manned objects in space. This term can also refer to the object while it is still on the ground.

This does NOT include launch vehicle components separated from the spacecraft.

UNITED STATES AIR FORCE SPACE SYSTEMS AND SPACE SUPPORT

SYSTEMS— All of the devices and organizations forming the space network. The network

includes spacecraft, ground control stations, and associated terminals. This includes systems that

are: (1) owned in whole or in part or leased by the Air Force, (2) operated and controlled or

directed by the Air Force, (3) furnished by the Air Force or leased to a non-Air Force

organization when the Air Force has retained the risk of loss, (4) systems for which the Air Force

has contractual development, contractual launch, or procurement responsibility, or (5) under test

by the Air Force.

UNIQUE SPACE SUPPORT EQUIPMENT (SSE)— Systems, equipment and facilities

required for processing, handling or transporting space systems and their components. SSE

examples include space-unique support vehicles, payload or launch vehicle ground transporters,

vehicle assembly equipment, launch pad facility and its associated equipment, equipment

required for test and checkout, and equipment for space system recovery. Components or

equipment commonly used in non-space applications, and not specifically configured for space

related use, are not considered SSE.

WEAPONS MISHAP— For the purposes of this instruction, a mishap that falls into one of the

following mishap categories: nuclear, guided missile, explosives and chemical agents, or

directed energy.


Attachment 2

WORKING WITH ACCIDENT INVESTIGATION BOARD (AIB) AND THE

ENGINEERING ANALYSIS GROUP (EAG)

A2.1. Space Safety investigations and accident investigations may be conducted simultaneously

and rely heavily on the receipt of the technical analyses conducted by the EAG, in arriving at

their findings and conclusions.

A2.1.1. There are many unique aspects of a space mishap investigation, including:

A2.1.1.1. Often, there is no terrestrial mishap site; the only tie to the ground will be the

launch or operations center.

A2.1.1.2. With on-orbit mishaps, the only source of information/evidence relating to the

mishap is often telemetry data. Commercial launch providers may have recordings (data,

audio, and video) of launch events that could be useful to the Air Force (The Aerospace

Corp STARS (Spacelift Telemetry and Recording System) facility.

A2.1.1.3. Space systems often do not have DoD maintenance personnel; contractors

provide support for launch and on-orbit operations.

A2.1.1.4. Most military satellites are bought in limited quantities; after the last is

launched, contractor support quickly dwindles as those who built the craft and have the

most knowledge of it have moved on to other projects.

A2.1.1.5. Many space mishaps, particularly on-orbit, are classified.

A2.2. The Engineering Analysis Group. The contractor and the system program office, in

coordination with the SIB and AIB presidents, may establish an EAG to assist in analyzing the

technical data from a mishap.

A2.2.1. The group is composed of contractor personnel (who must sign confidentiality

agreements), Air Force representatives, and other experts, as necessary.

A2.2.2. The EAG is not required to identify causes or to make recommendations, but may do

so.

A2.2.3. The EAG works with, but independently of, both the SIB and AIB. The EAG is not

subject to the direction or supervision of either board.

A2.2.3.1. The SIB and AIB may ask questions of the EAG; however, the EAG may not

discuss SIB comments with AIB members.

A2.2.4. The EAG may recommend to the SIB president and the AIB president that certain

non-privileged evidence and equipment be released in order that space launches may

continue.

A2.2.4.1. The AIB president, with the concurrence of the SIB president, shall release any

such evidence or equipment unless doing so will hinder the SIB. (T-2)

A2.2.5. Under no circumstances will the EAG take any action that will hinder the work of

the SIB or AIB. If at any time, the work of the EAG is thought to be hindering the ability of

the AIB to meet its objectives, the AIB president shall notify the HQ AFSEC/JA

immediately. (T-2)


A2.2.6. The SIB or AIB is not required to adopt any findings or conclusions of the EAG.