MISHAP INVESTIGATION _ REVIEW

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					MISHAP ANALYSIS
PROCESS


   Mr. George Borlase
   Commandant (CG-1134)
   Afloat Safety Division
   12 May 2009
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
   Safety & Environmental Health Manual COMDTINST
    M5100.47, Chapter #3, Enclosures : #2, #4, & #10.
             CGC HEALY
          CLASS “A” MISHAP




   17 August 2006, Time: 1555-2001 (local)
   500 NM Northwest of Point Barrow, Alaska
   2 fatalities in ice diving accident
                    CGC VALIANT
                  CLASS “B” MISHAP
   Due to movement of the
    cutter or movement of the
    crewmembers inside, the
    MSB rolled out of its cradle
    and struck the pier (a vertical
    distance of 16 feet)
   One crewmember was able
    to grab a monkey line and
    was struck in the back by the
    falling boat
   The other crewmember fell to
    the pier and then became
    pinned by the MSB which
    rolled onto him


                                     Injuries: Broken pelvis, internal
                                      bleeding, contusions on lower back and
    RESULTS                      
                                      right leg
                                      Damage Cost: $28,000
TANB TRAILER MISHAP CLASS
“C” MISHAP. ANT FT MACON
   Mishap result
    of SUV hitting
    left rear tire on
    trailer
    attempting to
    pass. No
    injuries.
    Damage
    Cost: Boat-
    $45K, Trailer-
    $11K
Class “D” Mishap
  Mishap result
of improperly
inflating
the air bladders
on 7 cube
JET DOCK.
 Cost: $2,261
 17 OP days lost
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
   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,
    MLC(kse), the area and operational
    commanders, by the unit experiencing the
    mishap.
   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” Mishaps must be reported within
  14 days.
 Class “D”& “E” 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 ANALYSIS

 Unit Response to a Mishap
 Mishap Analysis Board
 Mishap Analysis Report
    Mishap Analysis Board (MAB)
   Appointed and convened at the discretion of
    Commandant (CG-113) for most Class “A” and “B”
    mishaps.
   Class “C” and “D” HIPO mishaps depending on severity
    maybe convened at the unit level or tasked to the MLC.
   Members are chosen by their field of expertise as it
    relates to 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)
     ANALYSIS
     PROCEDURES
 Duties of MAB
 Sharing Evidence
                 Duties of MAB
   Review Mishap Response Checklist
     1. MAB Go-kit, Mishap MSG, Mishap Report, Chapter
      #3 & encl plus Blank CD & Laptop
     2. Investigation kit
     3. Proper PPE for weather, always follow unit
      protocols.
     4. Retrieve allpast mishaps reports related to similar
      types of mishaps.
     5. 72 Hour Pre-History forms are completed.
     6. Ensure blood & urine tests are complete for A & B
      Mishaps
       Duties of MAB- cont.
 7. Preserve all evidence both physical / electronic
 8. All conversations must be done in private to
  preserve integrity and confidentiality of board.
 9. President briefs command.
 10. Visit mishap site and take photo’s
 11. Send arrival msg.
 12. Update E-mishap if not done by unit.
 13. Establish secure room to interview witnesses.
 14. Establish interview schedule.





        Duties of MAB – cont.
 15. Priority over AIM to interview witnesses.
  Presidents establishes rules and order of
  interviewers.
 16. Review and collect unit records.
 17. Autopsy Reports –Medical Officer
 18. Media interest.
 19. AIM investigation commenced?
 20. President sends progress msg as needed.
          Duties of MAB-cont.
   21. Draft Mar
      Synopsis
      Mishap info – Time line
      Analysis –
      Causal & Contributory (HFACS)
      Conclusions
      Recommendations
      Signature page
      Appendices
          Initial msg
          MAB msg
          Personnel info
Duties of MAB-cont.
            Damage summary
            Transcripts of comms

            Cockpit vice recorder

            Films or video tapes

            Photographs

            Crew Statements

            Medical Officer Report

            Additional as required

   22. President briefs command discusses findings
Duties of MAB-cont.
   23. MAB President sends final MAB adjournment
    message. Permission for release from CG-113. Content
    of MSG:
       Short factual synopsis of mishap.
       Description of damage.
       Disposition of wreckage.
       Specific recommendations that MAB feels that field units need to
        know.
       No speculation or opinions
       Update E-mishap system regarding mishap if necessary.
          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.
                     MAR TIPS

   Properly formatted (privileged and non-privileged
    sections are segregated in the report) Privilege on right!
   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)
   An CD should accompany the MAR when sent to HQ.
     MISHAP REVIEW

 Endorsement process
 Commandant-level review process
    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)

    Program managers or their representatives review
     the MAR
    Complete CSB report within 90 days of receipt of
     MAR and endorsements
                 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’s Final Action msg normally takes
    about a year.
   All CSB recommendations are tracked in RATS to
    ensure completion.
Off-Duty Motor Vehicle &
Motorcycle Class “A” & “B” Mishaps
   2 Person Board convened by CG-113, board consists of
    motorcycle specialist when required.
   MAR includes police report, other related documents.
    Treated as a regular MAR and includes privileged info.
Major Changes to the Mishap
Analysis process.
   The vice COMDT will be review all Class “A” & “B”
    mishaps vice Chief of Staff.
   A digest of mishaps and lesson learned will be posted on
    line. Synopsis of key lessons learned published on semi-
    annual basis.
   All on–duty & off-duty class “A” &”B” mishaps will use
    DOD HFACS to determine causal & contributory factors.
   Chapter #3 Mishap Response, Investigation & Reporting
    will be rewritten into three sections Aviation, Afloat &
    Shore.
QUESTIONS?

				
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