MISHAP ANALYSIS PROCESS

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MISHAP ANALYSIS PROCESS

• Mr. George Borlase
• Commandant (CG-1134)
• Afloat Safety Division
• 12 May 2009

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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.

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Reference

• Safety Environmental Health Manual COMDTINST
  M5100.47, Chapter 3, Enclosures 2, 4, 10.

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CGC HEALYCLASS A MISHAP

• 17 August 2006, Time 1555-2001 (local)
• 500 NM Northwest of Point Barrow, Alaska
• 2 fatalities in ice diving accident

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CGC VALIANTCLASS 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 right leg
• Damage Cost 28,000

RESULTS
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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

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Class D Mishap

• Mishap result
• of improperly
• inflating
• the air bladders
• on 7 cube
• JET DOCK.
• Cost 2,261
• 17 OP days lost

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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.

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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.

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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.

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MISHAP ANALYSIS

• Unit Response to a Mishap
• Mishap Analysis Board
• Mishap Analysis Report

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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.

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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 crews mental/physical
  ability to return to duties)
• Safeguard electronically stored data
  (chart-plotter, engine data)

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ANALYSIS PROCEDURES

• Duties of MAB
• Sharing Evidence

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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

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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 photos
• 11. Send arrival msg.
• 12. Update E-mishap if not done by unit.
• 13. Establish secure room to interview witnesses.
• 14. Establish interview schedule.

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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.

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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

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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

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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.

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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.

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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.

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MISHAP REVIEW

• Endorsement process
• Commandant-level review process

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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
  units 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

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Commandants Safety Board (CSB)

• Program managers or their representatives review
  the MAR
• Complete CSB report within 90 days of receipt of
  MAR and endorsements

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CSB REPORT

• Class C D MARs 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 Staffs Final Action msg
  normally takes about a year.
• All CSB recommendations are tracked in RATS to
  ensure completion.

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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.

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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 onduty 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.

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QUESTIONS?