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Naval Safety Supervisor - Military manual on safety practices
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Human Error
CHAPTER 3 MISHAP CAUSES, PREVENTION, AND HAZARD ABATEMENT The Navy spends millions of dollars each year on damage, fatalities, injuries, and occupational illnesses. Mishaps  seriously  degrade  operational  readiness  and waste  tax  dollars.  Preventing  mishaps  depends  on identifying,  controlling,  eliminating,  and  correcting hazards.  When  preventive  efforts  fail  and  mishaps  do occur, investigating them thoroughly helps to determine the causes and prevent recurrences. The lessons learned from a mishap or near-mishap can yield valuable safety information. What  is  a  mishap?  Mishap  Investigation  and Reporting (OPNAVINST 5102.1C) defines a mishap as  any  unplanned  or  unexpected  event  causing personnel  injury,  occupational  illness,  death,  material loss or damage, or an explosion of any kind. Mishaps are usually a painful experience. After being involved in a mishap, most people look back and say  those  immortal  words,  “If  only  I...”  They  then finish the statement with “had or had not. . .” With that information  in  mind,  you  should  work  toward  making the words  If only I obsolete.  How  do  you  do  that?  You can’t  be  everywhere  at  the  same  time.  To  prevent mishaps, you have to get people to think about safety. You must promote enough interest to make people want to perform each task safely. We assume most people want to do their best; but remarkably, many people do not associate  best with safe. All Navy personnel must commit themselves to “think smart, think safety.” In this chapter, we discuss various statistics on mishap causes, prevention methods, and hazard abate- ment. MISHAP CAUSES Seldom  does  a  mishap  have  a  simple  cause.  A combination of factors, coming together under just the right  circumstances,  usually  cause  the  mishap.  A specific  chain  of  events  often  leads  to  a  mishap. Breaking any link in that chain can usually prevent the mishap. To prevent their recurrence, we need to know what those events and the contributing causes were. Normally, we divide cause factors into the following broad  classifications: 1. Primary cause. The primary cause, also called the immediate cause, is the actual, obvious cause of the mishap. For example, the cause of the sailor’s death was a head injury from a fall down a ladder. The primary cause of death was the head injury. 2. Contributing causes. Contributing causes are all the factors that made up the chain of events leading to the primary cause. Only through investigation can we determine these contributing causes. For example, the primary cause of death was a head injury from a fall down a ladder. The contributing causes could have been worn ladder treads, a missing heel on the sailor’s shoe, greasy  hand  rails,  the  sailor’s  rushing  down  the  ladder, or many other causes. The primary cause alone does not give  you  enough  information  to  prevent  recurrence  of the   mishap. Unsafe  acts  and  conditions  are  known  causes. Knowing how these unsafe acts and conditions develop will  make  your  mishap  prevention  training  more successful. You can stop mishaps by preventing or eliminating the causes. That is why all hands, especially supervisors, need to understand why mishaps occur. The more you know about the causes of mishaps, the better equipped you will be to prevent them. A practical definition of a mishap cause is anything and everything that has contributed to a mishap. That includes the primary and the contributing  causes.  The purpose of this broad interpretation of a mishap cause is to  encourage  you  to  adopt  a  broad  and  open  approach when identifying the cause of a mishap. Thus, do not focus all your attention on the mishap alone. Investigate everything  that  leads  to  the  mishap  both  directly  and indirectly before determining the probable cause or causes.  We  categorize  causes  as  follows: Human  error Maintenance  and  support  factors Administrative  and  supervisory  factors Material  failures  or  malfunctions Environmental factors 3-1

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