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Page Title: Investigator Training
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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  Officer’s  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  didn’t  realize  the  importance  of  the mishap  investigator’s  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) 4-6

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