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assuring a timely investigation.
The pre-mishap plan should also provide for
protecting the mishap scene as much as possible. For
example, if a ship spills a hazardous substance into the
harbor, what local agency or office do personnel from
the ship report that spill to? Is there assistance available
from a shore command? Can the local medical clinic
accept personnel contaminated with a chemical? All of
these questions can be answered with a pre-mishap plan.
Vital evidence can be lost if steps are not taken
quickly to secure the area. If feasible, the plan should
include phone numbers and points of contact for each
type of emergency. Pre-mishap plans are usually part of
the Command Duty or Staff Duty Officers Notebook.
INVESTIGATOR TRAINING
Whether a safety petty officer (SPO) or an
experienced safety manager, mishap investigators need
some training to ensure they can conduct a useful
investigation. Aviation safety officers receive extensive
formal training in aircraft mishap investigation
techniques. The Afloat Safety Officer Course currently
devotes 3 days to mishap investigation and training. The
Naval Safety School provides a mishap investigation
course for shore activities.
Most investigator training is done in house or on
board by a trained safety manager or safety officer. Good
training is the key to a good investigation; a good
investigation is the key to preventing mishaps. The
following example demonstrates the importance of a
good investigation:
A Seaman fell down a ladder and broke his
ankle. He lost more than 5 work days, so his
divisional safety petty officer (SPO) had to do
an investigation and prepare a report. The SPO
talked to one person who saw the SN fall. That
person said the SN was hurrying to get to chow
and slipped on the middle step. The SPO listed
the cause of the mishap as inattention and
rushing. The resulting mishap report was three
sentences long. The next week another sailor
fell down that same ladder and died.
What is wrong with this story? Perhaps the SPO was
not trained in conducting a mishap investigation.
Perhaps the SPO didnt realize the importance of the
mishap investigators job. When a formal mishap
investigation board investigated the second mishap, it
found the following evidence:
A
Worn ladder treads
No nonskid at either end of the ladder
Dirty ladder treads and greasy hand rails
A burned out light at the top of the ladder
Missing pins from the bottom handrail attach-
ment
The routine practice of requiring personnel who
used that ladder to work until chow was nearly
over resulted in personnel hurrying to the mess
decks
thorough investigation of the first mishap may
have prevented the fatality. The training of that
investigator may have saved a life.
INVESTIGATION KITS
In the movies we see civilian investigators with their
cameras, fingerprint kits, and magnifying glasses.
Although you may not investigate enough mishaps to
justify having a professional kit, you may find the
following equipment useful during evidence collection
and mishap scene evaluation. Most of the equipment is
common and will be available on board ship or at your
activity.
Blank labels or tags
A camera with flash (black and white/color film)
China marking pencils (red and black)
Manila envelopes
Felt-tip markers (red and black)
A two-cell, explosion-proof flashlight (with
spare batteries)
Graph paper
A hacksaw (frame and blades)
A 2 1/4-inch adjustable inspection mirror
A notebook
Plastic envelopes or small plastic bags with
scalable openings
Pliers (regular, needle nose, and wire cutters)
A pocket knife
Polyethylene rope (yellow)
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