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Page Title: Chapter 4 - Mishap Investigation Fundamentals
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CHAPTER  4 MISHAP INVESTIGATION FUNDAMENTALS Mishaps  seriously  degrade  operational  readiness and  waste  tax  dollars.  Mishap  prevention  depends  on hazard   identification,   elimination,   control,   and correction. We discussed these concepts in chapter 3. Despite  all  our  best  intentions  to  prevent  mishaps,  they still occur. When that happens, we must thoroughly investigate the mishap to prevent its recurrence. We must  review  every  possible  primary  and  contributing cause.  From  those  causes  we  can  learn  and  distribute lessons and plan corrective actions. In  this  chapter,  we  will  discuss  the  following information: Mishap   investigation   responsibilities Words and definitions investigations Privileged  information Testimonial   immunity Pre-mishap  plans Investigator  training Investigation  kits associated  with  mishap Investigative   procedures MISHAP INVESTIGATIONS The   purpose   of   a   mishap   investigation   is   to determine  the  primary  and  contributing  causes  of  the mishap. From those causes we can then plan corrective action  to  prevent  a  recurrence  of  the  mishap.  To  limit mishap  losses,  we  must  analyze  the  frequency  of potential  mishaps  and  identify  mishap  causes. Always investigate and report any mishap, near mishap, or situation that could result in a mishap; but conduct mishap investigations with care. You can use a number  of  investigative  techniques  to  collect  and examine  evidence,  take  good  witness  statements,  and determine the chain of events. Whether you are assisting a  safety  officer  with  a  command  or  local  investigation or serving as a member of a mishap investigation board, the  same  techniques  apply. You  may  be  required  to  help  conduct  a  safety investigation  of  a  mishap,  personal  injury,  or  fatality. OPNAVINSTS  3750.6Q,  5100.21B,  5100.23C,  and 5102.1C   contain   the   requirements   for   safety investigations.  Afloat  Mishap  Investigation  Handbook, NAVSAFECEN  5102/30,  contains  the  procedures  the investigator should follow for afloat mishaps. Certain  mishaps  are  reportable  to  the  Naval  Safety Center. Chapters 6, 7, and 8 discuss mishap reporting for shore, afloat, and aviation mishaps. Each community has its own reporting requirements. All mishaps, though, require investigation, whether or not they are reported outside  the  command. Investigation of mishaps is the responsibility of all levels  of  supervision,  from  the  first-line  supervisor  to the  commanding  officer.  Division  officers,  department heads,  or  representatives  appointed  by  the  commanding officer  usually  investigate  serious  injury  or  major property  damage  mishaps.  First-  and  second-line supervisors investigate nondisabling injury or minor property  damage  mishaps. An investigation is best conducted by the lowest level of supervision involved in the job or event that resulted  in  the  mishap.  For  instance,  if  improper maintenance or operation of a pump causes a mishap, the  immediate  supervisor  of  the  maintenance  person  or operator  often  provides  the  best  investigation. You  should  investigate  mishaps  that  occur  under your  supervision  for  several  reasons.  You  are  close  to the  jobs,  working  conditions,  and  your  personnel.  You know   the   details   of   jobs,   procedures,   hazards, environmental   conditions,   and   any   unusual circumstances  that  might  arise.  You  also  know  the experience  and  personal  characteristics  of  your personnel. This knowledge provides you with a good background for conducting a thorough investigation. Conducting  mishap  investigations  yourself strengthens your sense of responsibility for mishap prevention. While conducting mishap investigations, you  will  learn  about  the  hazards,  causes,  and  mishap conditions that are likely to recur. You must train new personnel, check for unsafe conditions and practices, and remind personnel about hazards. Since a supervisor has the greatest influence on mishap reporting, you must take positive steps to ensure the prompt reporting of all mishaps. Teach subordinates, especially  new  arrivals,  to  report  all  mishaps,  including the  “near  mishaps”   when  only  chance  prevented  a mishap. Make sure personnel understand that hazardous 4-1

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