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,
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
The investigators 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 persons
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, lets 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
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
Additional definitions are given in enclosure (2) of
OPNAVINST 5100.21B, Afloat Mishap Investigation
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
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.