Reviewing whether regulations and their
enforcement by all levels in the chain of command could
have contributed to the mishap is essential during a
mishap investigation. Standard operating procedures
(SOPs) might be unsafe. Safety standards might be
incomplete or missing from a technical manual. How
the command views and enforces the use of SOPs and
other procedures could contribute to the mishap.
Consider supervisory factors. Examine the
proficiency and physical condition of the supervisor.
Mishaps can result from an improper level of
supervision or a failure to require personnel to meet
personnel qualification standards (PQS). They can also
result from a lack of formal and informal training of the
supervisor and the crew.
Check the adequacy of the procedures and
precautions of the task being performed when the
mishap occurred. Examine these areas even when every
action seems to have been appropriate and to have
followed prescribed procedures. You may find
procedures are incorrect or inadequate. For example, if
you change, replace, or alter a piece of equipment, you
must update the technical manual. If you do not, the
operator or maintenance technician may accidentally
use incorrect procedures for a particular task. Not
posting the necessary instructions or removing them
from the work area can lead to procedural problems.
Instructions need to be available for reference in the
Do not assume personnel already know the
precautions to take when doing a job. Make sure they
look them up in a procedural instruction or technical
manual. Personnel must have these precautions
available when needed. Make sure procedures
contribute to mishap prevention by teaching personnel
to follow the safety precautions for every procedure they
MATERIAL FAILURES OR
Consider all material failures and malfunctions
thoroughly, whether the failures or malfunctions
occurred because of faulty design, defective
manufacture, or repair. That does not include failures
caused by normal wear and tear. Most mishaps blamed
on material failure may really involve maintenance
factors or human error.
When investigating material failures, especially
metal fatigue failures, never try to force the pieces back
together. That could alter or destroy the evidence needed
for more detailed laboratory analysis.
Environmental conditions are usually not cause
factors. For example, a cause of a mishap might be
excessive speed for existing sea conditions or failure to
secure for sea; but the high sea state did not cause the
mishap. We can attribute very few mishaps to acts of
God. Being struck by lightning maybe an act of God,
but being outside during a thunderstorm was a
contributing cause; therefore, the mishap was probably
Environmental factors can damage equipment and
cause injury to workers. Environmental factors include
extreme exposure to heat, cold, vibration, noise,
illumination, radiation, or atmospheric contaminants.
You may require electronic equipment to operate within
a narrow temperature range, for instance. Deviation
degrades performance and causes system failure.
Humidity also takes its toll through corrosion and
moisture accumulation. Entire systems are susceptible
to damage by extreme weather conditions that produce
abnormal winds, seas, and rain.
Although a mishap usually has only one primary
cause, it may have more than one contributing cause.
Alone, each contributing cause may not have caused the
mishap. However, one contributing cause may have
started a chain of events leading up to the mishap.
Preventive efforts must be directed toward all the
primary and contributing causes.
Mishap prevention is the process of eliminating
mishap-producing causes before a mishap occurs. It is
an organized effort to eliminate unsafe acts and unsafe
mechanical, physical, or chemical conditions. The
object of mishap prevention is to prevent mishaps from
occurring. If they have already occurred, the object is to
prevent them from recurring. Mishap prevention takes
place through two means:
The Navy Occupational Safety and Health
Deficiency Abatement Program (NAVOSH-
DAP), which identifies a hazard before a mishap
occurs and takes action to prevent recurrence
Mishap investigations, which reveal causes and
identify action needed to prevent recurrence