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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Getting below the surface to correct breakdowns
CAP National Safety Team and NHQ Safety
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?
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
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
Reviews only serious injuries
Blaming it on something that someone did
Concluding the mishap review too soon
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
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.
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.
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.
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.”
how it happened
why it happened
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.
REDUCTION IN MEMBER INJURY RATES,
FEWER MEMBERS AWAY FROM CAP ACTIVITIES,
IMPROVED MEMBER RELATIONSHIPS,
IMPROVED PRODUCTIVITY AND
HIGHER READINESS RATE.
To prevent these,
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
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
Collect Preliminary Data
Who has a role in the Mishap Analysis process?
Region Safety Officers
National Safety Team and NHQ Safety
Your Region Safety Officers
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?
Part II: The Nuts and Bolts
Collecting the facts
Completing the Preliminary Report
Identifying fact patterns
Completing the Summary Report
Camera w/extra film or discs, photo log
Paper (note pad and graph), pencil, ruler
Chalk or high visibility tape
Investigation forms and regulations
List of phone numbers
Decision: if hospitalization, etc. then contact NOC and provide info on the Preliminary Report
Take photographs and measurements
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
Should accompany photographs
Include locations of all equipment and personnel
Include distances and compass direction
Becomes part of the Mishap Review package
Copy for Safety Database input
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
Open-ended questions first
Directed questions to clarify
LG MX records, manufacturer
Manual references, codes
Injury or damage history and action plans
Other miscellaneous documentation
It is a guideline designed to point you in the right direction by identifying contributing factors that allow you to develop meaningful corrective action.
It will not cover every situation.
It is a worksheet.
People and Procedures
Personal Protective Equipment (PPE)
Tell the story with available info
Use only known facts
Include a description of the activity
Include extent of injury or damage
Was the member sent to the hospital
“Was the failure of the equipment a contributing factor?”
Ground equipment or tools involved
If yes, or unsure...answer the questions
Resources: local mechanics, logistics, manufacturer representatives
“Was the work environment a contributing factor?”
A condition, something tangible
Location of equipment or facilities
Size or layout of facilities
Slippery substances, trip hazards
“Was the job procedure a contributing factor?”
Identify substandard performance
Identify weakness in standards or procedures
Did the right people know and understand the procedures?
Ask why did the person or procedure fail?
Was the lack of, or misuse of PPE a contributing factor?”
Design of equipment
Muscular skeletal disorders
Did we anticipate the hazard?
Did we communicate the hazard? or did we accept the risk?
Records contributing factors states the fact patterns associated to a mishap.
Becomes part of the mishap review package
Entered into the mishap management database
What is the first step in the Mishap Review process?
The Contributing Factors Guideline is a process to help you identify causes of the mishap.
The mishap management database is used to record your findings as a factual narrative.
Opening: Explain your purpose
Ask open-ended questions
Repeat for clarification
Ask for suggestions
Part III: Closing the Loop
Assisting with the development of corrective action
Writing the report
Implementing and tracking corrective action
Factors that influence corrective actions include:
Impact on operation
Time required to implement
Extent of remedial training required
Acceptance by the member
Development and acceptance by the commander
All corrective action plans must have:
Estimated completion date
Use CAP’s mishap management database (Future Upgrades coming in 2012)
Wing CC inputs corrective action plan
Wing SE validates implementation and completion
Revise plan if necessary
Assessing the potential for severity helps to ensure the right priority is given to high risk mishaps
Corrective actions must be S.M.A.R.T.
All corrective actions must have an owner
Provide feedback to all members
Update safety database with corrective action info
“Try to gather all the facts so that you can discover
Win-Win Partnerships, p.153
Please feel free to send your questions and comments directly to
the National Safety Team and NHQ Safety @
Col Bob Diduch Frank Jirik
National Safety Officer Safety, CAP NHQ
P.O. Box 3036 105 S. Hansell St.
Trenton, NJ 08619 Maxwell AFB, AL 36112
609-731-5600 cell 800-227-9142 ext. 232