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
Mishap investigation responsibilities
Words and definitions
associated with mishap
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