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Page Title: Material Failures or Malfunctions
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ADMINISTRATIVE  AND SUPERVISORY FACTORS Reviewing   whether   regulations   and   their enforcement by all levels in the chain of command could have contributed to the mishap is essential during a mishap  investigation.  Standard  operating  procedures (SOPs) might be unsafe. Safety standards might be incomplete or missing from a technical manual. How the command views and enforces the use of SOPs and other  procedures  could  contribute  to  the  mishap. Consider   supervisory   factors.   Examine   the proficiency and physical condition of the supervisor. Mishaps   can   result   from   an   improper   level   of supervision or a failure to require personnel to meet personnel qualification standards (PQS). They can also result from a lack of formal and informal training of the supervisor  and  the  crew. Check  the  adequacy  of  the  procedures  and precautions  of  the  task  being  performed  when  the mishap occurred. Examine these areas even when every action seems to have been appropriate and to have followed   prescribed   procedures.   You   may   find procedures are incorrect or inadequate. For example, if you change, replace, or alter a piece of equipment, you must update the technical manual. If you do not, the operator  or  maintenance  technician  may  accidentally use  incorrect  procedures  for  a  particular  task.  Not posting the necessary instructions or removing them from the work area can lead to procedural problems. Instructions need to be available for reference in the work area. Do  not  assume  personnel  already  know  the precautions to take when doing a job. Make sure they look them up in a procedural instruction or technical manual.   Personnel   must   have   these   precautions available   when   needed.   Make   sure   procedures contribute to mishap prevention by teaching personnel to follow the safety precautions for every procedure they perform. MATERIAL FAILURES OR MALFUNCTIONS Consider all material failures and malfunctions thoroughly,  whether  the  failures  or  malfunctions occurred   because   of   faulty   design,   defective manufacture,  or  repair.  That  does  not  include  failures caused by normal wear and tear. Most mishaps blamed on material failure may really involve maintenance factors or human error. When investigating material failures, especially metal fatigue failures, never try to force the pieces back together. That could alter or destroy the evidence needed for  more  detailed  laboratory  analysis. ENVIRONMENTAL  CONDITIONS Environmental conditions are usually not cause factors. For example, a cause of a mishap might be excessive speed for existing sea conditions or failure to secure for sea; but the high sea state did not cause the mishap. We can attribute very few mishaps to “acts of God.” Being struck by lightning maybe an act of God, but  being  outside  during  a  thunderstorm  was  a contributing cause; therefore, the mishap was probably preventable. Environmental factors can damage equipment and cause injury to workers. Environmental factors include extreme  exposure  to  heat,  cold,  vibration,  noise, illumination,  radiation,  or  atmospheric  contaminants. You may require electronic equipment to operate within a narrow temperature range, for instance. Deviation degrades  performance  and  causes  system  failure. Humidity  also  takes  its  toll  through  corrosion  and moisture accumulation. Entire systems are susceptible to damage by extreme weather conditions that produce abnormal winds, seas, and rain. MISHAP PREVENTION Although a mishap usually has only one primary cause, it may have more than one contributing cause. Alone, each contributing cause may not have caused the mishap. However, one contributing cause may have started a chain of events leading up to the mishap. Preventive  efforts  must  be  directed  toward  all  the primary  and  contributing  causes. Mishap prevention is the process of eliminating mishap-producing causes before a mishap occurs. It is an organized effort to eliminate unsafe acts and unsafe mechanical,  physical,  or  chemical  conditions.  The object of mishap prevention is to prevent mishaps from occurring. If they have already occurred, the object is to prevent them from recurring. Mishap prevention takes place through two means: The  Navy  Occupational  Safety  and  Health Deficiency   Abatement   Program   (NAVOSH- DAP),  which  identifies  a  hazard  before  a  mishap occurs  and  takes  action  to  prevent  recurrence Mishap investigations, which reveal causes and identify  action  needed  to  prevent  recurrence 3-5

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