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Introduction to Mishap Reviews

Introduction to Mishap Reviews. Getting below the surface to correct breakdowns. Presented by CAP National Safety Team and NHQ Safety. Alaskan Grown. Helicopter Pilot. Alaska Flying – UH60L ESSS. This course requires focus, concentration, and a willingness to think different.

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Introduction to Mishap Reviews

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  1. Introduction to MishapReviews Getting below the surface to correct breakdowns Presented by CAP National Safety Team and NHQ Safety

  2. Alaskan Grown

  3. Helicopter Pilot

  4. Alaska Flying – UH60L ESSS

  5. This course requires focus, concentration, and a willingness to think different. This course will challenge us to change and set an example of change. This course will emphasize what you already will recognize as valuable. Ready to focus?

  6. Focus and Concentration

  7. Intro to Mishap Review: Training Objectives Why we review mishaps and the barriers to mishap reviews What causes injuries and damages How the process works and your role How to begin a mishap review Identifying causal factors Writing the factual narrative Guiding the Commander on corrective action Implementing and tracking the corrective action

  8. Part I: Theory In this part of the session we will cover: traditional reviews (investigations) and norms definition review of CAPR 62-1 why and what we should explore in a mishap review? barriers that may prevent us from doing a review the mishap analysis process roles and responsibilities

  9. Traditional Reviews or Norms Reviews only serious injuries Blaming it on something that someone did Concluding the mishap review too soon Makes assumptions Under reporting Fault-finding Punitive

  10. Remember, do not make assumptions!

  11. Panel Investigation

  12. Definitions (CAPR 62-2) Mishap (New definition): Any unplanned or unsought event, or series of events, that result, in or has the potential to cause death, injury, or damage to equipment or property. Accident: Serious, not so good, total loss, death Incident: Not as serious, more than first aid Minor Mishap: Minor scratches, flat tire – no rim damage, small cut, blisters

  13. Definitions Mechanical: Related to mechanical malfunction only; however are not a result of failure to perform routine maintenance. Near Miss: Any circumstance where the in-flight separation between aircraft constitutes a hazardous situation involving potential risk of collision. Weather: Related to unforeseen weather events, ex. Hail, high wind, flooding, etc.

  14. Definitions Vandalism: Acts of malice towards CAP property where a police report is filed. Pre-existing conditions: Medical conditions of a member that are undisclosed resulting in a mishap or failure of a member to follow the limitations set due to a pre-existing medical condition. Non-CAP: Mishaps that are not the responsibility of CAP, ex. A mishap occurring before or after a CAP activity where the Home to Work rule would apply.

  15. Definitions Other: Miscellaneous one-time occurrences that are not the result of human factors and do not fall into one of the other categories listed above.

  16. Definitions Safety Deviation: Any event that is perceived as an unsought safety act, most commonly defined as any act that is non-compliant with CAP rules, regulations, or other defined policies, as well as local, state, or national laws or regulations that could result in injury or damage to CAP members or equipment. These are “at risk” behaviors that occur in motion that involve CAP members, not to be confused with static risks, defined as hazards, that are identified in CAP’s Hazard reporting system, formerly known as a Form 26. The exception to this is aircraft in-air related which is defined as “near- miss.”

  17. Common Sense isn’t Common

  18. Why Review Mishaps? • Determine; what happened how it happened why it happened • Establish corrective actions to prevent it from happening again • It’s part of a safety culture

  19. The Goal The goal of no-fault mishap reviews is mishap prevention! To prevent injuries we must analyze to determine facts, conditions and circumstances of an incident. We use this information to identify contributing factors and develop corrective action.


  21. Mishap Investigations and Mishap Analysis is a part of a solid Safety Management System RM Logistics Training Trending Mishap Analysis Safety Database MX Procedures Behavior Based Safety Inspection PPE Observations Education Goals Motivation Accountability

  22. At-Risk Behavior Triangle • For every major injury • there are many more • minor ones (e.g. • Heinrich 1950) • Investigating and • preventing minor • mishaps will prevent • more serious ones 1 Accident We always investigate these 20-50 Incidents To prevent these, 600 Minor Mishaps we must investigate these 15,000 At-Risk Behaviors Decision Making Data

  23. At Risk Behavior?

  24. Barriers to Your Mishap Review Takes too much time Members don’t understand the need to report Can’t be bothered with the administrative work May result in punishment Reporting may cause the injury rate to go up Reporting may result in lost award

  25. Overcoming the barriers Tell all members why full reporting is important Don’t blame people for injuries Show concern about mishap Recognize those who report mishaps, near-misses, or safety deviations Do not use incentives which ONLY reward lack of injuries or damages

  26. The Mishap Analysis Process Mishap • secure the area • identify witnesses • take measurements and photos • report serious injuries to OCC Collect Preliminary Data • conduct interviews • use Causal Factors Guideline • review injury or damage history • conduct risk assessment Causal Factors • tell the story • document key findings • document corrective action plan Final Report • identify owner • develop time line Implement Plan • follow up with agents Provide Feedback • trends • validate plan • update corr actions Analyze

  27. Roles and Responsibilities Who has a role in the Mishap Analysis process? Commander Safety Officer Region Safety Officers National Safety Team and NHQ Safety

  28. Commander Responsibilities • Arrange for emergency medical services • Contact CAP National Operations Center (NOC) if applicable • Collect preliminary information • Appoint a mishap review officer • Develop corrective action plan after the mishap review is completed • Record causal factors and corrective actions • Forward the mishap review report to the Region Commander for review and approval. • Implement corrective action plan

  29. Safety Officer Responsibilities • Subject Matter Expert • Quality Control • Conduct Operational Risk Assessment • Validate Corrective Action Plan • Analyze for local trends

  30. Region Safety Officer Responsibilities • Ensure mishap reports are filed within 48 hours • Provide coverage and consultation as needed during the mishap review. • Review mishap review reports provided • Part of mishap review team • Maintain accurate records of equipment and bodily injury mishaps • Ensure mishap review training is conducted • Etc. • Etc. • Etc. Your Region Safety Officers Name Here

  31. National Safety Team and NHQ Safety Responsibilities • Review all mishaps and high risk reports and provide additional resources as required • Lead or assist in mishap analysis process • Trend for system wide implications • Track progress on corrective action plans and approve all final mishap reviews • Maintain injury/damage database, post review classifications • Notify and respond to applicable outside agencies • Maintain regulations

  32. Review Part I Fault-finding is an example of current investigation norms. Name at least 3 others. What is a mishap? Why do we review mishaps? What is the goal of a no-fault mishap review? What do we need to review? Who is the lead mishap review officer?

  33. BREAK 15 minutes Next: Part II: The Nuts and Bolts

  34. Part II: The Nuts & BoltsIn this part of the session we will cover: Collecting the facts Completing the Preliminary Report Interview techniques Identifying fact patterns Completing the Summary Report

  35. Mishap Review Tool Kit Camera w/extra film or discs, photo log Paper (note pad and graph), pencil, ruler Tape measure Chalk or high visibility tape Flashlight Investigation forms and regulations List of phone numbers

  36. First Step - Collect and Call Preliminary Report Decision: if hospitalization, etc. then contact NOC and provide info on the Preliminary Report Conduct interviews Take photographs and measurements Draw diagrams

  37. Collecting Facts - Photographs Take photographs before moving anything Photograph from several different angles Take more than you think you’ll need Panoramic and close up views Use a tape measure in photo Photograph from the operator’s point of view

  38. Collecting Facts - Diagrams Should accompany photographs Include locations of all equipment and personnel Include distances and compass direction

  39. Completing the Preliminary Report Becomes part of the Mishap Review package Copy for Safety Database input

  40. Preparing for the Interview Select a location for the interview Goal: hear and write down all info given Pencil and paper for you AND interviewee Keep witnesses separated until all interviews are completed Obtain a witness statement to review prior to the interview

  41. Interview Do’s • One-on-one only in a quiet room, no interruptions • Ask permission to ask questions and explain the purpose of the mishap review • Ask open-ended questions and speak slowly and deliberately • Take notes and repeat, be an active listener • Ask witness to diagram event • Eliminate physical barriers • Interview on site if necessary

  42. Interview Do’s ALWAYS • Stress that you want the facts • Stress that you want to prevent the next mishap • Take the extra time to get understanding

  43. Interview Techniques Ask: • Who was injured? • What happened? • Where were you? • When did it happen? (not simply time) • How did it happen? • Why did it happen?

  44. Interview Techniques Open-ended questions first • describe in your own words • what happened. • what did you see? • where were you standing? Directed questions to clarify • who gave you instructions? • what are the procedures?

  45. Interview Do’s • Be prepared with questions, references, procedures • Ask for their opinion or suggestions • Have paper available for notes • Make your interview like a conversation, comfortable • Thank them for their help

  46. Example of an interview?

  47. Who Should be Interviewed? • Those present when the mishap took place • The member involved in the mishap • Personnel who set up area • Members with technical expertise • The activity leader and/or unit commander

  48. Interview DON’Ts • Don’t ask leading questions or express opinions • Don’t arrive at premature conclusion • Don’t argue, accuse or imply blame • Don’t discuss things with other interviewers • Don’t interrupt the interviewee

  49. Interview - Verify • Information gathered in interviews must be verified • The witness may be mistaken • Erroneous information can adversely affect the investigation

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