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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.
MISHAP ANALYSIS PROCESSMr. George BorlaseCommandant (CG-1134)Afloat Safety Division12 May 2009Mishap 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.
  • 17 August 2006, Time: 1555-2001 (local)
  • 500 NM Northwest of Point Barrow, Alaska
  • 2 fatalities in ice diving accident
  • 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
  • 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 inflatingthe 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 ReportMishap 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 EvidenceDuties 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.
  • 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.
  • 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 processMAR 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 MARComplete CSB report within 90 days of receipt of MAR and endorsementsCSB 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.
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