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MISHAP INVESTIGATION REVIEW. Laura H. Weems Commandant (CG-1132) Shore and Sector Operational Safety Division. Mishap Reporting. Mishap Definition: Any unplanned, unexpected or undesirable event causing injury, occupational illness, death, or property damage/loss.

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mishap investigation review

MISHAP INVESTIGATION REVIEW

Laura H. Weems

Commandant (CG-1132)

Shore and Sector Operational Safety Division

mishap reporting
Mishap Reporting
  • Mishap Definition: Any unplanned, unexpected or undesirable event causing injury, occupational illness, death, or property damage/loss.
  • Non- Reportable Mishap Events: Minor Off-duty injuries, Non-Occupational illnesses, Intentional acts of violence, Intentional damage, Natural Disasters, & Normal wear & tear.
  • Fact finding not faulting finding, do not report punitive action, i.e. Pulled Qualifications.
reference
Reference
  • Safety & Environmental Health Manual COMDTINST M5100.47, Chapter 3, Enclosures: 2, 4, & 10.
  • ALCOAST 360/10 – Revision of Cost Thresholds for Mishap Severity
mishap classes
Mishap Classes
  • Class A
  • Class B
  • Class C
  • Class D
  • Class E
  • Class C & D HIPO
class a mishap
Class “A” Mishap
  • Fatality or permanent disability
  • Property damage $2M or greater
  • A cutter or aircraft is missing or abandoned recovery is impossible or impractical; beyond economical repair.
  • A small boat has reported value of $100K or more, is missing or abandoned, recovery impossible or impractical, beyond economical repair.
class a mishap cont
Class “A” Mishap (cont)
  • A mid air collision, regardless of severity.
  • Personnel are missing or missing in action.
class b mishap
Class “B” Mishap
  • Injury or occupational illness results in permanent partial disability.
  • Property damage or damage to cutter or aircraft is $500K or more or less than $2M.
  • Three or more personnel are inpatient hospitalized.
  • Small boat incurs repairable damage of $100K or more.
class c mishap
Class “C” Mishap
  • Injury or occupational illness results in: 1)any loss of time beyond the day or shift on which occurred; 2) placement of any individuals on limited or restricted duty status for more than 30 consecutive days; or 3) transfer of any individuals to a different job.
class c mishap cont
Class “C” Mishap (cont)
  • Resulting cost of reportable property damage or damage to aircraft or cutter is $50K or more but less than $500K.
  • Small boat repairable damage is $50K but less than $100K.
  • Person falls overboard from vessel, pier or other structure or equipment during CG operations.
class c mishap cont1
Class “C” Mishap (cont)
  • Grounding, capsizing, or rollover/knockdown occurs which is greater than 90 degrees from an even keel.
class d mishap
Class “D” Mishap
  • Occupational injury or illness occurs requiring more than simple first aid but does not meet criteria of a Class “C” mishap. Personnel placed on limited duty status or restricted duty for less than 30 consecutive days.
class d mishap cont
Class “D” Mishap (cont)
  • Cost of property damage for non-aviation is $5K or more but less than $50K.
  • Cost of property damage for aviation mishap is less than $50K.
  • Accidental firearm discharge, elect. shock, or fire occurs that does not meet higher classification.
class d mishap cont1
Class “D” Mishap (cont)
  • A near midair collision occurs.
  • Aviation Reportable Mishap occurs.
class e mishap
Class “E” Mishap
  • Aviation mishaps involving engine damage only. (Flight, Flight-Related or Ground)
  • Foreign Object Debris(FOD) Damage Incidents.
class c d hipo
Class “C” & “D” HIPO
  • Near misses, lesson learned events or other events with a High Potential (HIPO) for injury, damage or CG wide implications are reportable even though they result in MINIMAL or NO DAMAGE or PERSONAL INJURY or would otherwise not be reportable as a Class “C” or “D” or not reportable as a mishap. Mishaps that could be greater than a Class “C” or “D” Mishap.
class a or b mishap reporting
Class “A” or “B” Mishap Reporting
  • Immediate telephone report within 4 hours to Flag Plot at CGHQ. Include location, time, and injury to personnel and damage to CG property.
  • Message within 12 hours to COMDT CG-113, HSWL SUPACT (se), the area and operational commanders, by the unit experiencing the mishap. By entering the info into the E-Mishap online system, it can be used to generate the message report.
  • An update to the E-Mishap system should be made within 72 hrs and by the MAB if convened.
class c d mishap reporting
Class “C” & “D” Mishap Reporting
  • Class “C” Mishaps must be reported within 14 days.
  • Class “D” Mishaps must be reported within 21 days.
  • All operational mishaps shall be shared by within the operational community by message within the applicable time frames.
mishap investigation

MISHAP INVESTIGATION

Unit Response to a Mishap

Mishap Analysis Board

Mishap Analysis Report

unit response to a mishap
Unit Response to a Mishap
  • Secure and protect mishap site until Mishap Analysis Board (MAB) arrives on scene
  • Document the mishap site (e.g. photographs, video, notes) in the event that the mishap site must be disturbed prior to MAB arrival
  • Collect Human Factors evidence (urine/blood samples of survivors, 72-hour pre-mishap questionnaire, document crew’s mental/physical ability to return to duties)
  • Safeguard electronically stored data (chart-plotter, engine data)
  • Assemble crew training and administrative records
mishap analysis board mab
Mishap Analysis Board (MAB)
  • Appointed and convened at the discretion of Commandant (CG-113) for most Class “A” and “B” mishaps. May delegate on a case by case basis to the AREA, HSWL or District.
  • Class “C” and “D” HIPO mishaps depending on severity maybe convened at the unit level or tasked to the HSWL.
  • Experts on subject-matter related to mishap (for afloat mishaps: boat drivers, cuttermen, engineers, safety specialists, command cadre of similar units outside mishap unit’s chain of command, medical member/flight surgeon)
investigation procedures

INVESTIGATION PROCEDURES

Duties of MAB

Sharing Evidence

duties of mab
Duties of MAB
  • Establish plan of action:
    • Assume custody of evidence.
    • Send arrival message- message sent from unit should indicate MAB. (USCG LONG ISLAND//MAB)
    • MAB has precedence over AIM investigation in interviewing witnesses.
    • Make list of witnesses including Command Cadre - allow 45 min – 1 HR between witnesses. Witnesses must complete 72 hour Pre-History form.
    • Gather evidence – logs, charts, pre-mishap plan, unit SOP, communications, parts, pictures, videos, prior mishaps, etc.
duties of mab cont
Duties of MAB- cont.
  • Review HFACS Human Factors Analysis using the Department of Defense Human Factors Analysis and Classification System (DoD HFACS)
  • Review Mishap Report .
  • Review 72 hour Pre-History Forms.
  • All MAB members participate in interview.
  • Witnesses shall sign a Witness Statement Offer of Confidentiality Advisory Form (Figure (2-1) in Enclosure (2) at the beginning of the interview & indicate if they want their statements treated as confidential.
duties of mab cont1
Duties of MAB – cont.
  • If granted confidentiality at discretion of board president, their statement will not be shared with other investigations (AIM) or outside the CG.
  • Oral statements captured by MAB recorder. Witnesses review their oral statements for accuracy but do not sign them.
  • Written statements from witnesses should only be used to verify accuracy of oral statements. NOT included in MAR.
  • If witness has committed an offense under UCMJ, MAB President shall contact CG-113 immediately!
  • Call back witnesses as needed.
duties of mab cont2
Duties of MAB-cont.
  • Establish a timeline using statements, logs etc.
  • Determine crew injuries & experience
  • Survey damages to unit/equipment/private property.
  • Determine causal factors & contributing factors.
  • Determine HFACS (Flight Surgeon if assigned)
  • Review of Medical Records by Flight Surgeon.
  • Make recommendations on how to prevent similar mishaps in the future
  • Update Mishap Report.
  • Send departure message to CG – 113, indicate it is from MAB as well as causal factors and recommendations.
  • Brief CO prior to departing unit.
slide26

If MAB discovers critical safety information that seriously impacts Coast Guard operations, CG-113 must be notified immediately so this information can be disseminated to the fleet !

sharing evidence
SHARING EVIDENCE
  • Logs, maps or equipment involved in the mishap will be shared with the AIM investigation.
  • Pictures/ videos/reenactments produced by the MAB or witnesses granted confidentiality will NOT be shared with the AIM or any other investigation.
mishap analysis report mar
Mishap Analysis Report (MAR)
  • Properly formatted (privileged and non-privileged sections are segregated in the report)  See enclosure (2) of SEHM
  • Select human factors from HFACS and include a short explanation why each one relates to the mishap
  • It is not necessary to enclose documents unless they reveal unusual circumstances that are essential to clearly understanding the report or mishap (simply state that all documents were analyzed and found satisfactory)
  • Due to the privileged nature of MARs, copies must be strictly controlled by CG-113
mishap review

MISHAP REVIEW

Endorsement process

Commandant-level review process

mar endorsement review
MAR Endorsement & Review
  • MAR is submitted to CG-113 within 21 calendar days of completing on-site mishap investigation (extensions granted by CG-113)
  • CG-113 retains the original MAR and sends a copy to mishap unit for endorsement
  • Subsequent endorsements completed by mishap unit’s chain-of-command
  • Unit and each level of chain-of-command has 21 calendar days to forward their endorsement and the copy of the MAR to the next destination
  • Final destination: CG-113
commandant s safety board csb
Commandant’s Boat Safety Board (CBSB)

Commandant’s Shore Safety Board (CSSB)

Commandant’s Safety Board (CSB)
  • Program managers or their representatives review the MAR
  • Complete CSB report within 90 days of receipt of MAR and endorsements
commandant s safety board report
Commandant’s Safety Board Report
  • This report is privileged
  • Elements of the report:
    • Synopsis
    • Classification and cost of mishap
    • Review of human factors selected by MAB
    • Causal and contributing factors
    • Additional findings
    • Recommendations to Chief of Staff
    • CSB Report (with MAR and endorsements as enclosures)
csb report
CSB REPORT
  • Class “C” & “D” MAR’s generated by the MLC or District may be reviewed by a CSB.The CSB makes recommendations and the program managers take action as directed by the CG Chief of Staff.
  • The complete process from investigation to sending out the Chief of Staff Final Action msg takes about a year.
  • All CSB recommendations are tracked in RATS to ensure completion.