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Chapter 4 - Mishap Investigation Fundamentals
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Naval Safety Supervisor - Military manual on safety practices
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Mishap Investigation Responsibilities - 14167_59
conditions cannot be corrected unless they are reported. To fully support these efforts, follow up on all reported mishaps  with  an  investigation  and  corrective  measures, MISHAP  INVESTIGATION RESPONSIBILITIES The commanding officer ensures all mishaps are investigated, no matter how minor. Serious mishaps will be investigated by the cognizant Echelon 2 command (ashore), a mishap investigation board (afloat), or a standing  aviation  mishap  board  (aircraft  mishaps).  The safety officer or manager, as principal assistant to the commanding officer, will ensure a mishap investigation is  conducted  for  less  serious  mishaps.  The  actual informal investigation may be conducted by a safety petty  officer,  safety  supervisor,  division  officer,  or  safety manager. The   investigator’s   responsibilities   include answering  the  following  questions:  What?  Where? When? How? and Why? Notice that you are not trying to find  WHO caused the mishap. Your job is to make an objective inquiry to learn the circumstances and causes, not to place the blame. Each mishap shows a failure or defect in a person’s actions,  a  piece  of  equipment,  an  environmental condition,  a  procedure,  or  a  combination  of  these  items. You  should  thoroughly  examine  each  situation  to determine  all  causes,  both  primary  and  contributory. An important concept for you to understand is that mishaps and injuries are two separate occurrences. An injury is not the mishap; it is the result of the mishap, The investigation of an injury or damage uncovers the cause of a mishap. WORDS AND DEFINITIONS ASSOCIATED WITH  MISHAP  INVESTIGATIONS Before continuing, let’s define some of the terms with which you as an investigator need to be familiar: Evidence—  Any  parts,  pieces,  wreckage,  logs, statements,  records,  photographs,  or  other  items  that may  provide  insight  into  the  mishap.  Physical  evidence consists  of  only  tangible  materials  that  were  not  staged or  derived  by  the  investigator. JAG Manual Investigation—  An official legal search to uncover facts concerning a mishap. The JAG manual investigation is conducted separately from the safety  investigation  and  can  result  in  punitive  or administrative  action. Mishap—  Any unplanned or unexpected event causing  personnel  injury,  occupational  illness,  death,  or material loss or damage. It also could be an explosion of any kind whether or not damage occurs. Mishap investigation— A review of the events leading  to,  during,  and  following  a  mishap.  The command  involved  conducts  the  investigation  using  the procedures   outlined   in   OPNAVINSTS   3750.6Q, 5100.21B,  5100.23C,  or  5102.1C. Mishap   Investigation   Board—   A   formally appointed body assigned to investigate a serious mishap. Boards are appointed for shore, afloat, and aviation activity mishaps, depending upon the seriousness of the mishap.  A  mishap  investigation  board  provides  its findings  in  a  Mishap  Investigation  Report  (MIR)  or  a Shore Safety Investigation Report (SSIR). Near Mishap— A  hazardous  or  potentially  risky occurrence  in  which  injury  or  damage  was  avoided merely by chance. Witness Statement— An oral, written, recorded, or dictated account of what the witness to a mishap saw, heard, felt, or perceived. Witness statements taken for safety investigtations are never taken under oath. They can   contain   opinions,   beliefs,   and   perceptions. Statements  taken  by  an  afloat  or  aviation  mishap  investi- gation  board  may  become  privileged  information.  If  a shore   mishap   investigation   board   takes   witness statements,  the  statements  are  covered  under  testimonial immunity. Additional definitions are given in enclosure (2) of OPNAVINST 5100.21B, Afloat Mishap Investigation and Reporting. PRIVILEGED  INFORMATION Privileged  information  is   that   information voluntarily  provided  under  a  promise  of  confidentiality or information that would not have been discovered but for  information  voluntarily  provided  under  a  promise  of confidentiality.  The  analyses  of  findings,  conclusions, and recommendations of the afloat and aviation mishap investigation boards and any endorsements made by the board are privileged information. Also privileged are the calculations and deductions the board used in making those  analyses. A   complete   and   comprehensive   mishap investigation is an essential tool in identifying the cause of  a  mishap  and  thereby  preventing  recurrence. Traditionally, the only source of mishap information is a Judge Advocate General (JAG) investigation. This investigation  detemines  accountability  and  culpability. 4-2

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