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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

Introduction to MishapReviews

Getting below the surface to correct breakdowns

Presented by

CAP National Safety Team and NHQ Safety

slide6

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?

intro to mishap review training objectives
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

part i theory
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

traditional reviews or norms
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

definitions capr 62 2
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

definitions
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.

definitions15
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.

definitions16
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.

definitions17
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.”

why review mishaps
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
the goal
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.

what does it mean in operational terms
What Does it Mean in Operational Terms?

REDUCTION IN MEMBER INJURY RATES,

FEWER MEMBERS AWAY FROM CAP ACTIVITIES,

IMPROVED MEMBER RELATIONSHIPS,

IMPROVED PRODUCTIVITY AND

HIGHER READINESS RATE.

mishap investigations and mishap analysis is a part of a solid s afety m anagement s ystem
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

at risk behavior triangle
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

barriers to your mishap review
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

overcoming the barriers
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

the mishap analysis process
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

roles and responsibilities
Roles and Responsibilities

Who has a role in the Mishap Analysis process?

Commander

Safety Officer

Region Safety Officers

National Safety Team and NHQ Safety

commander responsibilities
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
safety officer responsibilities
Safety Officer Responsibilities
  • Subject Matter Expert
  • Quality Control
  • Conduct Operational Risk Assessment
  • Validate Corrective Action Plan
  • Analyze for local trends
region safety officer responsibilities
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

national safety team and nhq safety responsibilities
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
review part i
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?

slide34

BREAK

15 minutes

Next:

Part II: The Nuts and Bolts

part ii the nuts bolts in this part of the session we will cover
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

mishap review tool kit
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

first step collect and call
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

collecting facts photographs
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

collecting facts diagrams
Collecting Facts - Diagrams

Should accompany photographs

Include locations of all equipment and personnel

Include distances and compass direction

completing the preliminary report
Completing the Preliminary Report

Becomes part of the Mishap Review package

Copy for Safety Database input

preparing for the interview
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

interview do s
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
interview do s43
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
interview techniques
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?
interview techniques45
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?
interview do s46
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
who should be interviewed
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
interview don ts
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
interview verify
Interview - Verify
  • Information gathered in interviews must be verified
    • The witness may be mistaken
    • Erroneous information can adversely affect the investigation
additional sources of supporting documentation
Additional Sources of Supporting Documentation

LG MX records, manufacturer

Pre-operations checklist

Manual references, codes

Inspection results

Training records

Injury or damage history and action plans

Blue prints

Police reports

Other miscellaneous documentation

contributing factors guidelines
Contributing Factors Guidelines

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.

identifying contributing factors
Identifying Contributing Factors

Equipment

Work Environment

People and Procedures

Personal Protective Equipment (PPE)

Ergonomics

Industrial Hygiene

Management System

preliminary report description of mishap
Preliminary Report - Description of Mishap

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

contributing factors equipment
Contributing Factors - Equipment

“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

Examples

contributing factors work environment
Contributing Factors - Work Environment

“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

Housekeeping

contributing factors people and job procedures
Contributing Factors - People and Job Procedures

“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?

contributing factors personal protective equipment
Contributing Factors - Personal Protective Equipment

Was the lack of, or misuse of PPE a contributing factor?”

Hearing protection

Safety vests

Protective eyewear

contributing factors ergonomics
Contributing Factors - Ergonomics

Design of equipment

Muscular skeletal disorders

Repetitive motion

contributing factors management system
Contributing Factors - Management System

Did we anticipate the hazard?

Did we communicate the hazard? or did we accept the risk?

summary report
Summary Report

Records contributing factors states the fact patterns associated to a mishap.

Becomes part of the mishap review package

Entered into the mishap management database

review part ii
Review Part II

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.

part ii review interview techniques
Part II Review - Interview Techniques

Opening: Explain your purpose

Ask open-ended questions

Repeat for clarification

Ask for suggestions

Thank You!

slide65

BREAK

15 minutes

Next:

Part III: Closing the Loop

part iii closing the loop in this part of the session we will cover
Part III: Closing the LoopIn this part of the session we will cover:

Assisting with the development of corrective action

Writing the report

Implementing and tracking corrective action

Tool kit

developing corrective actions
Developing Corrective Actions

Factors that influence corrective actions include:

Effectiveness

Feasibility

Impact on operation

Time required to implement

Extent of remedial training required

Acceptance by the member

Development and acceptance by the commander

corrective action smarts
Corrective Action Smarts

Specific

Measurable

Achievable

Realistic

Timed

Sustainable

corrective action plan
Corrective Action Plan

All corrective action plans must have:

Owner

Estimated completion date

writing the report just the facts ma am
Writing the Report“just the facts ma’am”
  • History
    • Tell the story using only facts
  • Mishap Review
    • Who was interviewed
    • What was photographed or diagrammed
    • Procedures and training reviewed
  • Findings
  • Corrective Action
    • Based on findings
    • Owner
    • Timeline
provide feedback
Provide Feedback
  • To all affected members
  • Get input on corrective action plan
  • Distribute a preliminary report when necessary
  • Update members on progress
tracking corrective action
Tracking Corrective Action

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

review part iii
Review Part III

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

slide75

Chinese leader Deng Xiaoping said it this way:

“Try to gather all the facts so that you can discover

the truth.”

Win-Win Partnerships, p.153

slide76

Where is the next mishap, incident, accident going to occur?

Please feel free to send your questions and comments directly to

the National Safety Team and NHQ Safety @

safety@capnhq.gov

QUESTIONS?

contact information
Contact Information

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

907-350-7559 cell

safety@capnhq.gov