Investigation of the Building M6-794 Roofing Fatality, Type A Mishap

Abstract

The Building M6-794 Roofing Fatality Mishap Investigation Board (Board) was commissioned to gather information; analyze the facts; identify the proximate causes, root causes, and contributing factors relating to the mishap; and recommend appropriate actions to prevent a similar mishap from occurring in the future. During the investigation of this mishap, the Board also examined the fall protection policies of other NASA Centers and operating locations to gain an understanding of how those entities conduct fall protection, as well as the degree to which fall protection is standardized across the Agency